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SUMMER 2005 




With clinical 
surgeon Atul 
Gawande highlights 
the value of simple 
human exchanges. 


if w 








of 1 873, served Harvard Medical 
School for nearly 50 years, bot 
the Jackson Professor of Clinic 
Medicine and as a visionary n 
ical education reformer. Shattu 
helped establish the School's 
Department of Tropical Medicin- 
and endowed its chair. His support 
of research on industrial hazar 
also played an influential role 
the establishment of the Harva 
School of Public Health. 

S I \l M F R : 5 • V O L 1 Ml 7 J . NUMBER 1 



Letters 3 

Pulse 4 

All new: a national mental illness survey; 
a medical education dean; a series of con- 
sumer health books; a finding about vio 
lence among adolescents; the name of a 
history of medicine resource at Harvard; 
hospital rankings; and websites on cultur 
ally competent care and stem cell research 

Editorial 7 

When parents are skeptical about vacci- 
nating their children, by Nicole Martin 

Curbside Consultation 8 

Has the blurring of commercial and acad 
emic interests helped or hurt patients? 
by Richard Wurtman 

Bookmark LO 

A review by Elissa Ely of FranzBoas: An 
Illustrated Biographx 

Bookshelf 11 

Benchmarks 12 

New approaches to old maladies 

Class Notes 58 

In Memoriam 61 

Fred S. Rosen 

Obituaries 62 


Reinventing the Wheel 1 6 

How can doctors avoid becoming white-coated cogs in the machinery 
of medicine? 


Back to the Future 20 

A young physician's lighthearted take on an imaginary medical forbear 
highlights the timeless nature of the School's mission. 


Luck of the Draw 22 

A new graduate appreciates the good fortune that led him to HMS — and 
the wisdom of those who helped him through it. 



Listening With Our Eyes 26 

Technologically correct medicine cannot trump the 
primacy of the bond between physicians and patients. 


Truth and Consequences 32 

On the heels of selective reporting of data by 
pharmaceutical companies, a medical editor 
calls for transparency in clinical trials. 


The Data Game 36 

A physician journalist explores the impact of 
the evolution of media on the public's access to 
medical information. 



Map of the World 40 

The dean of HMS explains how a world newly 
flattened by technology is giving rise to 
fresh dimensions in medicine. 



Reports from the Classes 

Cover photograph byjodi Hilton 

Harvard Medical 


U L L E T I N 

In This Issue 


congratulate another class of graduating physicians, and itself, 
on a job well done — deservedly so. Yet complacency takes up a 
remarkably small fraction of these exercises. Medicine is not by 
nature a complacent undertaking, and the current environment of medicine 
hardly fosters that state of mind. 

To take the most obvious case in point, physicians are now caught in the middle 
of a three-way struggle between those who receive care, those who pay for it, and 
those who produce and market the chemicals and machinery required to provide 
care. As in any struggle, knowledge is power, but a little knowledge may be a dan- 
gerous thing. Thus, both the ownership of medical information and the manage- 
ment of that information have become fault lines in health care in this country. 

In this issue, Jeffrey Drazen 72, editor-in-chief of the New England Journal of Medi- 
cine, provides an account of the role played by half-truths and limited access to 
trial results in the marketing of COX-2 inhibitors. More broadly, Drazen addresses 
the underlying question of who actually owns the information provided by volun- 
teers in clinical trials. He is, in essence, demanding an end to the private owner- 
ship of the data these volunteers yield. 

Timothy Johnson takes on the question of what happens when information is, 
perhaps, excessively free. Instant reporting, on-demand news, and unfiltered 
facts, factoids, and falsehoods are all becoming realities thanks to new technolo- 
gies. What is easy to foresee is how the requisite hardware will evolve. Less obvi- 
ous is whether evidence of intelligent design will appear in the content that it 
delivers. To be useful, information needs brakes and filters. How will they be 
inserted into tomorrow's medical news? 

Within a single institution — namely HMS — the acceleration of information 
flow permitted by new technologies appears to be a generally Good Thing. As 
Dean Joseph Martin reports in his survey of changes at the School, dependence 
on paper-based records and communication is waning as electronic libraries and 
intranet feedback are waxing. Both the effectiveness and the economy of commu- 
nication appear to be benefiting as a result. 

But Charles Hatem '66 and Atul Gawande '94 caution us not to be seduced into 
thinking that communication with a patient can be improved by any technology 
that fails to take account of the crucial clinical act of listening, on all the available 
channels, to the signals the patient is sending. The messages may be coded or inar- 
ticulate, but they must be heard and heartfelt if the physician is true to his or her 
calling. This archaic, delicate, improbable, and inefficient but profoundly effective 
human activity seems ever more threatened. But somewhere away from the din of 
advertising and the scrimping of third- party payers we can only hope there will 
continue to be a way for one person to listen seriously to another in the act we 
think of as caring for the patient. 


William Ira Bennett '68 


Paula Brewer Byron 


Beverly Ballaro, PhD 


Janice O'Leary 


Elissa Ely '88 


Judy Ann Bigby '78 

Rafael Campo '92 

Elissa Ely '88 

Daniel D. Federman '53 

Timothy G. Ferris '92 

Alice Flaherty '94 

Atul Gawande '94 

Robert M. Goldwyn '56 

Perri Klass '86 

Victoria McEvoy 75 

James J. O'Connell '82 

Nancy E. Oriol 79 

Anthony S. Patton '58 

Mitchell T. Rabkin'55 

Eleanor Shore '55 


Laura McFadden 


< v A*l IM jk^Wfr" 


Steven A. Schroeder '64, president 

A. W. Karchmer '64, president-elect 1 

William W. Chin 72, president-elect 2 

Susan M. Okie 78, vice president 

Rodney J. Taylor '95, secretary 
Kathleen E. Toomey 78, treasurer 


Wesley A. Curry 76 

Timothy G. Ferris '92 

Gerald S. Foster '51 

Edward D. Harris, Jr. '62 

Linda S. Hotchkiss 78 

Lisa I. Iezzoni '84 

Katherine A. Keeley '94 

Christopher J. O'Donnell '87 

Rachel G. Rosovsky '00 


George E. Thibault '69 


Patrick Rivera 


Harold J. Bursztajn 76 
Joseph K. Hurd, Jr. '64 

The Harvard Medical Alumm Bulletin is 

published quarterly at 25 Shattuck Street, 

Boston, MA 02115 « by the Harvard 

Medical Alumni Association. 

Phone: (617) 384-8900 • Fax: (617) 384-8901 


Third class postage paid at Boston, 

Massachusetts. Postmaster, send form 3579 

to 25 Shattuck Street, Boston, MA 02115 

ISSN 0191-7757 • Printed in the U.S.A. 





The Outsiders 

I read with great interest "Pride and 
Prejudice," the feature on the history 
of African Americans at HMS, in the 
winter issue of the Bulletin. Prejudice 
was a way of life years ago, and 
unfortunately it remains with us 
in various forms. 

The Irish Catholics in Boston — 
before they eventually took over 
local politics — had to deal with the 
"Irish need not apply" phenomenon. I 
believe that Catholics and Jews nei- 
ther advanced in academic positions 
at HMS nor were selected in appro 
priate numbers until the late 1950s. 
It is my understanding that the first 
Catholic to be made a full professor 
at HMS was appointed in 1959. He 
was Thomas Fitzpatrick, my mentor 
in dermatology at Massachusetts 
General Hospital. I also believe that 
the School's first Jewish full profes- 
sor, other than the ones at Beth Israel 
Hospital, was Morton Swartz '47 at 
Massachusetts General in 1960. 

This not-so subtle prejudice was cer- 
tainly not confined to HMS; for years four 
of the twenty-four students annually 
admitted to Dartmouth Medical School 
were Jewish — never more, never fewer. 
That was the way it was, and no one said a 
hell of a lot about it. 


Southern Discomfort 

When I entered HMS in the fall of 1933, 
an unusual incident opened my eyes to 
the nature of prejudice. During a 
microbiology course, the class was 
awaiting the arrival of a lecturer who 
was scheduled to teach us about vari- 
ous syphilis tests. When Professor 
William Hinton '12 walked into the 
room, one of the students rose from his 
seat, descended the steps, and dramat 
ically strode out of the room — by the 
opposite door. I felt bewildered. 

Later I learned that the student, a 
southerner, could not tolerate being 

taught by an African American. Had 
Nora Nercessian's book on the history of 
students of African descent at HMS been 
available then, I might have understood 
what was happening. Thanks to Eve 
Higginbotham 79 for her good article. 


Charged with an Error 

Although eight years in Boston immu- 
nized me to its sports parochialism 
to some extent, I was nonetheless 
astounded to read in a caption in the 
spring issue that Ted Williams was "the 
only player ever to bat higher than .400 
in a season." In fact, other players — 
none of whom played for the Red Sox — 
achieved this feat. Kindly advise your 
copyeditors not to let the 2004 season 
go to their heads. 


It's clear that your copyeditor does not 
share Ted Williams's exceptional eye- 

sight, in describing him as the only 
player ever to bat higher than .400 
in a season. The Splendid Splinter 
was the most recent player to do 
so, in 1941. Modern tendencies, 
including skilled relief pitching, 
Likely make that milestone as diffi- 
cult to achieve as Joe DiMaggio's 
56 game hitting streak, also estab- 
lished in 1941. 


I greatly enjoyed the discussion of 
the relationship of vision to artis- 
tic and athletic performance in the 
spring issue. Some consider excep- 
tional visual acuity to be a common 
trait among accomplished athletes, 
most famously Ted Williams. It is 
i/^Jj said that his vision and discipline 
were so legendary that umpires 
would not call third strikes on 
'""it t ■ him, perhaps acknowledging that 
it a pitch had been a strike Ted 
would have swung his bat. 

Great as he was, Ted was not the only 
player to hit over .400 in a season. He was 
the last player to do so, hitting .406 by 
getting six hits in eight at-bats in a clou 
bleheader on the final day of the 1941 sea- 
son. But Teddy Ballgame may truly retain 
his status as the last player to do it, as his 
feat is now 64 years old. 


Editor's note: The caption accompanying 
the photo of Ted Williams in our spring 
issue should have described Teddy Ball- 
game as the last player in baseball's mod- 
ern era to finish a season with a batting 
average higher than .400. The Bulletin 
regrets having dropped the ball. 

The Bulletin welcomes letters to the editor. 
Please send letters by mail (Harvard Medical 
Alumni Bulletin, 25 Shattuck Street, Boston, 
Massachusetts 02U5); fax (617-384-8901); or 
email (hulletin( a> hms.har\'ard.cdu). Letters may 
he edited [or length or clarity. 




Early Warning System 


U.S. mental health tracking 
survey show mixed results on 
progress following a decade's 
worth of advances in therapeutics, aware- 
ness campaigns, and greater health plan 
coverage of mental health care. The survey, 
known as the National Comorbidity Sur- 
vey Replication (NCS-R), is the most 
recent in a series taken every ten years to 
assess the mental health of the country. 

In a set of four papers published in the 
June issue of Archives of General Psychiatry, the 
survey authors report that the percentage 
of people receiving mental health treat- 
ment has doubled in the last decade; that 
about half of all Americans will experience 
a mental health disorder at some time in 
their lives, though most disorders will be 
mild; that these disorders often go untreat- 
ed; and that even when treatment does 
occur, the care provided likely will not 
meet recommended guidelines. The study 
also found that mental disorders gain the 
strongest foothold among young people. 

"Given the enormous personal and 
societal burdens of mental disorders, 

these observations should lead us to 
direct a greater part of our thinking 
about mental health interventions for 
children," said Ron Kessler, HMS pro- 
fessor of health care policy, who direct- 

ed both the NCS-R and the original sur- 
vey. "We should focus on early interven- 
tions aimed at preventing progression 
of primary disorders and the onset of 
multiple disorders." ■ 

Keeping the Dean in Dienstag 


has been appointed the new dean for medical education at HMS. From 1998 to 
2003, Dienstag served as the School's faculty associate dean for admissions, and 
in September 2003, he was named its associate dean for academic and clinical 

Since November 2004, Dienstag has aided Joseph Martin, dean of HMS, in guid- 
ing the Program in Medical Education and the Medical Education Reform Initiative. In 
revamping medical education, he has focused on community-wide involvement, meet- 
ing with basic science and clinical department heads and the chairs of the depart- 
mental executive committees. He also has brought together the preclinical and basic 
science course directors and core clerkship directors to engage them in reform efforts 
and listen to their thoughts about the proposed changes. 

"We are fortunate," Dienstag says, "to have so many dedicated teachers on our 
faculty, and I am excited about working with them to realize our vision for enhancing 
the medical education experience of our students." ■ 


Consumers Alerted 


tions Division of HMS recent 
ly inaugurated its partnership 
with McGraw-Hill by issuing 
six consumer health books. Begun last 
year, the joint program will produce 
about ten consumer health books a year 
by HMS faculty physicians. 

"For 30 years, Harvard Medical School 
has included education of the public as 
part of its educational mission," said 
Anthony Komaroff, editor in chief of 
Harvard Health Publications and an 
HMS professor of medicine at Brigham 
and Women's Hospital. "Our faculty 
have an extraordinary breadth and 
depth of knowledge about maintaining 
good health and treating disease, and 
many are skilled at conveying their 
knowledge to a lay audience. HMS is 
reaching millions of people with high 
quality health information." 

Among the first books to he published, 
Living Through Breast Cancer by Carolyn 
Kaelin, director of the Comprehensive 
Breast Health Center and HMS assistant 
professor ot surgery at Brigham and 
Women's Hospital, draws on the author's 
experiences both as a breast cancer sur 
geon and a breast cancer patient. 

David M. Nathan, director of the Dia- 
betes Center at Massachusetts General 
Hospital, has demonstrated that life- 
style changes can go a long way toward 
prevention and treatment. In Beating 
Diabetes, he and the chief dietitian at 
the center, Linda Delahanty. outline a 
program of exercise and diet to sharply 
improve glucose tolerance and prospects 
for long-term health. 

High cholesterol, a major risk factor 
for cardiovascular disease, and ways to 
manage it are the subjects of Mason 
Freeman's Lowering Your Cholesterol Free 
man is chief of the Lipid Metabolism 
Unit at Massachusetts General Hospital. 

Research on pain associated with dis- 
ease by Ralph Metson and colleagues 
revealed that people with chronic sinusitis 

Deadly Exposure 


HMS researchers have found that young teens who witnessed gun violence were 
more than twice as likely as nonwitnesses to commit a violent crime themselves 
within two years. The research appears in the May 27 issue of Science. 

The investigation, a five-year project that included interviews with more than 
1 ,500 children and teenagers from 78 Chicago neighborhoods, used statistical 
advances and extremely detailed information about the study subjects to go 
beyond correlations and associations and estimate causation. 

By grouping together and comparing teens with similar likelihood of exposure, 
some of whom were and some of whom were not witnesses to violence, the 
researchers were able to isolate the independent contribution made by seeing 
gun violence. And it turned out to be large, swamping previously identified 
influences such as poverty, drug use, and being raised by a single parent. 

To address violence effectively, says Felton "Tony" Earls, HMS professor of 
social medicine and principal investigator of the study, the challenge for social 
medicine researchers is to define its fundamental nature — is it a product of fami- 
lies, akin to a hereditary disorder? Or is it like an environmental contaminant, 
lurking in some communities and leaving others unscathed? Based on this study's 
results, showing the importance of personal contact with violence, Earls believes 
the best model may be that of a socially contagious disease. 

"Preventing one violent crime may prevent a downstream cascade of 'infections,'" 
Earls says. "And the lessons learned in Chicago should be broadly applicable." 

The study was part of the Project on Human Development in Chicago 
Neighborhoods, a major interdisciplinary initiative aimed at deepening soci- 
ety's understanding of the causes and pathways of juvenile delinquency, adult 
crime, substance abuse, and violence. ■ 

Tai Viinikka is a former intern at Focus. 

reported higher levels of pain than those 
with heart disease, lower back problems, 
and other conditions. Such findings by 
Metson, an HMS clinical professor of otol 
ogy and laryngology at the Massachusetts 
Eye and Ear Infirmary, form the basis of the 
hook Healing Your Sinuses, which addresses 
quality of life, new treatment techniques, 
and computer- enhanced sinus surgery. 

Focusing on another quality of life 
issue, loss of memory, Aaron Nelson, HMS 

assistant professor of psychology in the 
Department of Psychiatry at Brigham and 
Women's Hospital, describes the latest 
research on preventing memory loss in his 
book AchievingOptimal Memory. 

Finally, in Ear, rlax, and Be Healthy, 
W. Allan Walker, director of the HMS 
Division of Nutrition, guides parents 
in forming healthy eating habits for their 
children through the stages of growth 
from birth to eight years old. ■ 




Don't Know Much About History? 


and Special Collections Department 
recently changed its name to the Center 
for the History of Medicine. The new 
name reflects the breadth of archives 
that contain virtually all of the great 
works in the history of medicine as well 
as many lesser known, fascinating 
materials. At any given time, scholars 
may be encountered delving into such 
treasures as the George Burgess 
Magrath Library of Legal Medicine, the 
collections forming the National 
Archives of Plastic Surgery, the Hyams 
Collection of Hebraic Medical Litera- 
ture, or more than 800 books printed 
before 1501. ■ 

Diverse Resources 


to share resources and exchange information on initiatives in cross- 
cultural education and training. The Culturally Competent Care Educa- 
tion Committee at HMS created the site in collaboration with the Office 
for Diversity and Community Partnership. 

Culturally competent care involves tailoring delivery to meet patients' social, cul- 
tural, and linguistic needs in an effort to improve outcomes and eliminate disparities 
in health care. Cultural competence education has been deemed critical in preparing 
doctors to meet the health needs of a growing, diverse population, and the Liaison 
Council on Medical Education now has standards that require cultural competence 
education as part of undergraduate medical curricula. 

The Institute of Medicine report "Unequal Treatment" recommended cultural 
competence education as a method of improving doctor-patient communication and 
eliminating racial and ethnic disparities in health care. The report stated that racial 
and ethnic minorities receive lower quality health care, even when access to insurance 
and socioeconomic status are controlled. 

In addition to race and ethnicity, lower quality health care is often associated with a 
person's national origin, limited English proficiency, religion, age, social class, gender, 
sexual orientation, physical or mental disability, immigration status, and obesity. 

Called the Culturally Competent Care On-Line Resource Center, the site serves stu- 
dents, faculty, staff, and the public. Among the educational resources that it provides 
are a primer covering the principles and practical applications of cross-cultural care, a 
compilation of case studies, and links to other organizations' teaching curricula. Visit to learn more about the On-Line Resource Center. ■ 

Institutional Divvying 


Hospital (MGH) and Brigham and 
Women's Hospital (BWH) have earned 
spots on the U.S. News & World Report 
annual Honor Roll of America's Best 
Hospitals. MGH ranked third nationally, 
while BWH ranked 12th among the 16 
hospitals on the list. 

MGH also was among the top ten in 
12 specialties, including psychiatry for the 
tenth year in a row, cardiology, digestive 
disorders, geriatrics, gynecology, hormon- 
al disorders, kidney disease, neurology 
and neurosurgery, orthopedics, respiratory 
disorders, rheumatology, and urology. 

BWH ranked in the top ten in six cat- 
egories — cardiology, digestive disor- 
ders, gynecology, hormonal disorders, 
kidney disease, and rheumatology — and 
in the top 50 in the categories of can- 
cer, geriatrics, neurology and neuro- 
surgery, orthopedics, respiratory disor- 
ders, and urology. 

Among the other Harvard-affiliated insti- 
tutions, Children's Hospital ranked second 
in pediatrics. Massachusetts Eye and Ear 
Infirmary ranked second in ear, nose, and 
throat, and fourth in ophthalmology. Dana- 
Farber Cancer Institute ranked fourth in 
cancer, while McLean Hospital ranked 
fourth in psychiatry. 

Spaulding Rehabilitation Hospital 
moved up from eighth last year to sixth 
in rehabilitation, and Beth Israel Dea- 
coness Medical Center ranked 1 2th in 
hormonal disorders, 21st in digestive 
disorders, and 24th in geriatrics. ■ 

Cellular Communications 


about stem cell research, the Harvard 
Stem Cell Institute has launched a 
website that explains the basics of 
stem cell biology. The website also 
describes the institute's mission, which 
is to advance the science of stem cells 
from the laboratory to clinical applica- 
tions. Visit 
for more information. ■ 




The Best Defense 


Rancher. At the age of five, I found the oral polio vac 
cine an appealing alternative to a stick in the arm. In 
my second year of medical school, I learned the Sabin 
vaccine's other major advantage: it conferred mucosal immuni 
ty. I balked, though, at the live vaccine's serious downside. 
Between 1961 and 1997 an average of nine Americans a year devel- 
oped vaccine-associated paralytic polio. Since the Centers for Dis- 
ease Control and Prevention implemented an all-inactivated vac 
cine approach in 2000, however, no such cases have occurred. 

By eradicating deadly illnesses, vaccines have become hall 
marks of modern civilization. When I was a child in the 1980s, 
I received all my scheduled immunizations. My parents had 
grown up in an era in which polio posed a very real threat, a 
time when Elvis Presley received the intramuscular Salk vac- 
cine to promote public awareness. 1 never questioned the need 
tor vaccines; I considered them part of the litany of tasks I was 
supposed to complete, like homework and chores. 

Since then, the medical community has come to understand 
the natural history of chicken pox and the virus that causes it, 
varicella zoster. The short- and long-term risks of varicella 
infection are known to be small. Conversely, we have had vari- 
cella vaccine for only ten years. 

But even after only a decade of tollow up, it is clear that the 
vaccine saves lives. Between 1990 and 1994, the United States 
had an average of 145 varicella-related deaths a year; from 
1999 to 2001, that rate had been cut nearly in half. At the pop- 
ulation level, these data are compelling. The number of people 
requiring the vaccine is large, yet the intervention is relative- 
ly benign and carries an invaluable payoff. 

Although research has answered the mortality question, 
others remain. How can we predict whether the Perry girls 
will be more or less susceptible to future chicken pox or zoster 
than immunized children? It is encouraging that vaccinated 
people with so-called breakthrough varicella have mild skin 
manifestations that tend to be less infectious than classic vesi- 

Mrs. Perry revealed that rather than vaccinating her 
children she had "ordered" chicken pox by sending a 
pair of her daughter's pajamas to a friend with the virus. 

I felt shocked, therefore, when I met a mother who had 
declined vaccines for her children. Mrs. Perry had three play- 
ful, talkative girls whom she taught at home, so school-entry 
requirements did not factor into her decision. During her con- 
versation with my primary care preceptor, she revealed that 
she had "ordered" chicken pox by sending a pair of her eldest 
daughter's pajamas home to a friend with the disease. The 
three girls soon developed spots. 

Why, I wondered, would Mrs. Perry subject her children to 
two weeks' worth of unnecessary itching and possible scar- 
ring? As I considered the issue further, I realized that Mrs. 
Perry was merely sticking to the familiar. She had probably 
experienced a benign course of chicken pox as a child, and 
rather than subject her daughters to a relatively new vaccine, 
she preferred the au naturel approach. She likely was 
unaware that the vaccine had been shown to reduce the inci- 
dence of varicella encephalitis; she had probably never even 
heard of that condition. Before routine vaccination, about one 
in a million American schoolchildren died from varicella. 

In a sense, Mrs. Perry's choice was based on ages' worth of 
evidence. Giovanni Filippo first described chicken pox in the 
sixteenth century, and in 1767, the English physician William 
Heberden recognized it as a disease distinct from smallpox. 

cles. But as vaccine induced immunity wanes over time, 
boosters may be needed to prevent adult cases of chicken pox. 

With the growth of our elderly population, zoster — or 
shingles — is becoming a more important public health issue. 
A recent placebo-controlled trial among adults aged 60 and 
over showed a greater than 50 percent reduction in zoster 
incidence after vaccination. These patients had all been infect- 
ed previously with wild-type strains, possibly strengthening 
their cell- mediated immunity relative to vaccinated patients. 
Perhaps people who are vaccinated as children will need to 
receive earlier or larger booster doses to prevent zoster. 

Despite the unknown burden of long-term morbidity, the 
up-front mortality benefits of childhood varicella vaccina 
tion remain clear. The Department of Health and Human 
Services has established target immunization rates for 2010 
of 90 percent among children 19 to 35 months of age and 
greater than 95 percent at school entry. In the interest of 
children's well-being, we must strive to promote these goals. 
Unfortunately for skeptical parents, no institutional review 
board will approve a randomized trial comparing vaccines 
with unwashed pajamas. ■ 

Nicole Martin '06 is a fourth-year student at Howard Medical School 



Tossed in Translation 


found themselves embroiled in the ethics of trans 
lating their findings into useful drugs. They didn't 
worry that acceptance of consulting fees, indus- 
trial grants, or patent royalties might jeopardize their scientif- 
ic objectivity or credibility. Many scientists of my generation, 
though, have decided to weather those risks; indeed, some 
investigators at the National Institutes of Health (NIH) are 
considering moving to institutions with less restrictive poli- 
cies on commercial relationships. Others suspect that society 
suffers when distinctions between publicly supported and 
commercial investigations blur. One such skeptic was my 
mentor, Julius Axelrod. 

Julie loved science. Weeks before he died last year at the age 
of 92 he was still visiting his old NIH laboratory and helping 
younger investigators design the simple, elegant experiments 

healthy human subjects. Finally I'd draw on my medical 
background to identify diseases that might respond to any 
drugs that could affect the process I'd discovered. 

Shortly after I arrived at MIT in 1968, my laboratory found that 
surprisingly low doses of tryptophan could increase production 
of the neurotransmitter serotonin in the rat's brain. We described 
our finding in leading journals and confidently awaited its appli- 
cation to serotonin- associated disorders, such as stress-related 
insomnia. It was indeed applied; by the late 1970s the annual mar 
ket for tryptophan supplements had reached $300 million. The 
amino acid, however, was being misused: Not only were suppliers 
selling it in doses that varied over a 20-fold range, but they were 
also failing to provide accurate ad\ice about its best administra- 
tion, such as not taking it with a glass of protein-rich milk. 

Tragically, in 1989, a new commercial preparation of trypto 
phan, generated by a newly engineered microorganism, killed sev- 

"Fve had to confront, almost daily, complex ethical issues that have 
arisen from my — and my university's — receipt of corporate funds, 
provided as patent royalties, research grants, or consulting fees." 

that were his trademark. Such experiments allowed him to 
make major discoveries about how the brain works, such as the 
uptake process, which terminates the actions of serotonin and 
other neurotransmitters. Another was a pain-relieving chemi- 
cal, acetaminophen, now known commercially as Tylenol; 
when he published that finding in 1948 he neither thought to 
have it patented nor manifested an interest in participating in 
its development as a drug. Julie hoped, of course, that his dis- 
coveries would translate into new medicines. But to him, and 
to most of his generation, drug development was something 
pharmaceutical companies did, not research scientists. 

My expectations differed. By the time I joined Julie's lab in 
1962 as a research fellow 7 , neuroscientists were learning enough 
about brain transmitters to understand how certain drugs 
worked. I decided to use my medical training both to discover 
information about the brain and to apply that knowledge to 
treating neurological and psychiatric diseases. I formulated a 
three-stage strategy. First, using laboratory animals, I would 
try to find a previously unknown biochemical process in the 
brain — measuring blood levels of melatonin, for example, or 
identifying the amino acids that control serotonin production. 
Then I'd determine whether the same process operates in 


eral dozen Americans because the microorganism also produced 
two previously unknown toxins. None of these people would 
have died had the developers carried out standard Phase I safety 
testing on the new commercial preparation. I worried that I had 
erred by not staving involved in the process of tryptophans tran- 
sition to a drug. But I also couldn't think of anv way I might have 
compelled the companies selling tryptophan to solicit my ad\ice. 

In 1980 the power of university scientists to affect the fate of 
their discoveries reached a watershed with passage of the Bayh 
Dole Act. It had not escaped Congress's notice that troublingly few 
of the federally funded basic-science discoveries taking place at 
universities were being translated into useful treatments. The leg- 
islature concluded that this situation might improve if universities 
were given the right to patent those discoveries, to license the 
patents to companies that would develop them expeditiously, and 
to maintain some association with the development process. 

MIT — and, ultimately, most universities — established a tech- 
nology licensing office to implement these processes. Soon 
thereafter the director of MIT's office informed me that if I ever 
wanted to see my discoveries become medications, I needed to 
work with his office to help MIT patent them and to find 
licensees that would develop them. Without patent protection, 


he explained, pharmaceutical companies had no incentive to 
undertake the risky business of developing a new drug if a 
competitor could market the same drug, a short time later, 
after having covered none of its development costs. 

Many of my laboratory's discoveries have since been 
patented — always by MIT — and then licensed, and a few 
have become useful therapeutic products. But I've had to par 
ticipate in all phases of this translation process and to learn 
about fields — such as patent law and drug regulation — that 
never concerned Julie's generation. And I've had to confront, 
almost daily, complex ethical issues that have arisen from 
mv — and my university's — receipt of corporate funds, pro 
vided as patent royalties, research grants, or consulting fees. 

Consider, for example, melatonin. In the 1960s, Julie and I 
had shown that rat pineal glands produce the hormone mela 
tonin only when the animals are in the dark. In 1975 my MIT 
colleague Harry Lynch and I discovered that blood melatonin 
levels in people are at least ten times higher at night than 
during the day. My laboratory confirmed the connection 
between melatonin and sleep, first by showing in 1993 that it 
promoted sleep onset, then in 2001 that it enabled melatonin- 
deficient, older people to stay asleep. The correct melatonin 
dose — 0.3 mg — turned out to be just the amount needed to 
raise blood melatonin levels to what they normally are, at 
nighttime, in healthy young adults. 

MIT patented this use of melatonin, and I expected many 
to benefit, especially elderly people who tend to awaken dur- 
ing the night. But then major patent and regulatory prob- 
lems arose: because the correct dose of melatonin was low, 
MIT elected to patent only doses up to 1.0 mg, believing that 
the Food and Drug Administration (FDA) would eventually 
approve melatonin as a drug and limit its use to the maxi- 
mally effective 0.3 mg dose. 

But the FDA decided not to treat melatonin as a drug; 
rather, it allowed the hormone to be marketed as a dietary 
supplement, which meant the dosage would remain unregu- 
lated. This allowed companies to sell it at high doses to cir- 
cumvent the MIT patent. Such megadoses quickly rendered 
the melatonin ineffective: when the brain is repeatedly bom- 
barded with excessively large amounts of a hormone like 
melatonin, it stops responding because the hormone's recep- 
tors become downregulated. Thus, many of the people who 
might have benefited most from melatonin's use lost its effect 
alter a few days and then stopped taking it. 

Only in the past year have companies finally started to sell 
melatonin at the correct dose. Now MIT will receive royal- 
ties — and I, as the inventor who created the intellectual 
property, will receive about 30 percent of these. And there- 

in lies a potential ethical problem: Could someone argue 
that I recommended that people buy the low dosage 
because I receive royalties from those sales? Money wasn't 
my motivation, but I believe I have a duty to inform people 
about my potential conflict of interest. 

This obligation to fully disclose should carry over, I believe, 
to all financial relationships between scientists and corpora 
tions, including consultantships, substantial lectureships, 
and laboratory research support. Disclosure is particularly 
important when the scientist's career invokes addressing the 
public, writing review articles, or editing journals. Con- 
sumers have the right to any information that could raise 
questions about a scientist's objectivity — even when the sci- 
entist in question is a Julie Axelrod. 

In Julie's case, of course, it's unlikely the question would ever 
have arisen, since his choice to steer clear of the translation 
process shielded him from the ethical consequences of financial 
involvement. It may also have cost society a few good drugs. ■ 

Richard Wurtman '60, the Cecil H. Green Distinguished Professor at 
MIT, directed the MIT Clinical Research Center for 20 years. 




Franz Boas 

An Illustrated Biography 

by Norman Francis Boas '45 (Seaport Autograph Press, 2004) 


B % f I relatives. I treasure a photo taken about 20 years 
^^MM I a g° m the lobby of the Golden Nugget casino in 
I Las Vegas. A horseshoe of muscular, poker-faced 
men are posing in front of a wall papered with one million dol- 
lars. In the center, half a foot shorter than anyone else, stands a 
bald man. He is squinting at the camera 
through Coke-bottle glasses. This is my 
great-uncle Morris Shapiro. He was 75 
then and, although pushing 100 now, is 
still one of the finest Texas Hold'em play- 
ers in the world. Family lore has it that 
he put a number of us through graduate 
school. He is my claim to fame. 

Norman Francis Boas '45, retired from 
his position as assistant clinical professor 
of medicine at Yale University, has a proud 
family claim in a different sphere of society. 
He writes about it in FranzBoas: An Illustrat- 
ed Biography. The man known as "Grosspa- 
pa" Boas to his grandson was Professor 
Boas to the world: founder of anthropolo- 
gy as a science in the United States, men- 
tor to the likes of Margaret Mead and 
Ruth Benedict, creator of the concept of 
cultural relativism, and, in more than 650 
books and articles, enemy of the notion of 
racial or ethnic superiority. His was a long 
and stupendous life, retold factually here, 
with pages of grainy photographs that 
become more arresting as their subject 
becomes more obviously remarkable. 

"If I do not become really famous, I do not know what I will 
do," Franz Boas wTote hungrily to his sister when he was only 
15. Born in 1858 to a Jewish merchant in Germany, he studied 
physics, math, and geography. He also took up dueling and was 
scarred in college by a series of anti-semitically fueled fights. 

His doctoral dissertation was about the color of water, but 
while working on it, he managed to write five other theses as 
well. Then his broad mind, larger than any single science, 
became interested in psychophysics — the study of how 7 physi 
cal forces affect human behavior. When he was 25 years old, he 
arranged a famous trip to the Arctic, where conditions require 
ultimate human adaptations. Preparation included learning 
astronomy, meteorology, magnetism, anthropometry, Inuit 
languages, Danish, photography, and cartography. There 
was probably no time left to master Texas Hold'em. 

posing here as a seal-hunting Inuit, 
rejected notions of cultural superiority. 

Boas traveled 2,400 miles over the next year by dogsled. on 
foot, and by boat, mapping hundreds of coastal miles, eating 
blubber, keeping a fastidious 500 page journal in pencil (ink 
froze), and studying how land conditions affected Inuit migra- 
tion. This trip, and later trips where he studied Vancouver 
Island Indian tribes, gave him data for his theory of cultural rel- 
ativism. One culture, he argued, is never superior to another. 
Instead, each is equally conditioned by need and each is per- 
fectly created to serve itself. 

Dramatic, sometimes lurid tales followed Boas back from his 
international adventures, and his work was not everywhere 
welcomed. When he founded an anthro- 
pology program at Clark University he 
proposed measuring public school chil- 
dren in Worcester using anthropomet- 
rics. The local paper promptly identrned 
him as someone who "fooled around with 
the topknots of medicine men.. .and toyed 
with the war paint of bloodthirsty Indi- 
ans." The proposal was voted down. 

Nor were all of his research methods 
palatable by current standards. While 
working at the Museum of Natural His 
tory in New York, he once asked the 
explorer Robert Peary to "bring a mid- 
dle-aged Eskimo [from Greenland] to 
stay here over the winter. [This will] 
enable us to obtain leisurely-informa- 
tion." Peary brought back six. Without 
sufficient local immunity, four of them 
died of infections while leisurely sharing 
their information. 

Yet in his later years, Boas grew into 
moral as well as scientific greatness. His 
grandson writes about this with beautiful 
pride. When some of his anthropometric 
techniques were used to "prove" white 
races superior to non-white, and Aryan superior to non Aryan, 
the elder Boas dueled this time with intellect, not steel. After his 
books were burned in Nazi Germany, he responded by serving as 
chairman of the American Committee for Democracy and Intel 
lectual Freedom. In the United States, he opposed the 
inequitable poll tax, which prevented many African Americans 
from voting. At the age of 80, still not finished, he published a 
600 page treatise on race and culture. 

His mission accompanied him to the end. In 1942, during a 
faculty lunch, Boas began a talk with the words, "I have proved 
a point about race." Then he collapsed. If one can make judg- 
ments about death — a tricky idea to be undertaken carefully — 
the end of this life was one more proof of its passion. ■ 

Elissa Ely '88 is a psychiatrist at the Massachusetts Mental Health Center. 










K /. ■ . C lr- UO ] 

Creative Healers 

A Collection of Essays, Reviews, and Poems 
from The Pharos, 1938-199$, compiled 
and edited by Edward Day Harris, Jr. '62 
(Alpha Omega Alpha. 2004) 

This collection anthologizes 75 physi 
cian written essays, poetry, reviews, and 
articles that have appeared in The Pharos. 
the magazine published by the medical 
honor society Alpha Omega Alpha. In it 
readers will find a timeless piece on the 
value of intellectual curiosity, an exami 
nation of the role oi the presidential 
physician, and a history ol the lobotomy 
sharing the spine with a review of Satur 
day Night Fever 

Two Sweaters for My Father 

Writing About Knitting, by Pern klass "86 
(XrX Books, 2004) 

Klass turns her writing skills to the Zen 
of knitting. Her characteristic humor 
and honesty are woven into each piece 
as she recalls how, as a pediatric intern, 
she used knitting to help her stay awake 
during lectures and explores how knit- 
ting has helped her clarify the essential 
nature of her relationships. 

Up to the Mountain 

Wade Hampton Frost. Pioneer Epidemiologist, 
1880-1938.b\ Thomas M. Daniel '55 
(University of Rochester Press, 2004) 

Daniel, retired from his position as pro- 
fessor of international health at Case 
Western Reserve University, details 
Frost's life and work in this biography. 

Frost was the first professor of epidemi- 
ology at The Johns Hopkins University, 
and he trained many of the nations 
public health leaders. Some of his con- 
tributions include the development oi 
methods tor tracking influenza epi- 
demics and the use of age cohorts in 
longitudinal studies. 

The New Antidepressants 
and Antianxieties 

\\ hat You Seed to Know About Zoloft. Paxil. 
Wcllbutnn. Effcxor. Clonazepam, Ambien, and 
More, by William S. Appleton '61 
l^id edition: Plume, 2004) 

As the number of patients taking med- 
ication for depression and anxiety con- 
tinues to rise, so does the number of 
drugs available for treatment. Appleton 
shares his latest research and uses case 
studies to illuminate the advantages 
and disadvantages of the newest drugs 
on the market. The book also addresses 
anger disorders, which are only now 
emerging as recognized diagnoses. 

Surgery and Beyond 

by Frank J. Lepreau '38 (Old Harbor 
Publishing, 2005) 

This memoir chronicles Lepreau's life 
beginning with his years at Dartmouth, 
his time at HMS, and his stint as a gener- 
al surgeon in Fall River, Massachu- 
setts. The book then recounts the ten 
years Lepreau spent working in Haiti at 
the Hopital Albert Schweitzer, where 
he had a very successful record of pul- 
monary surgery for tuberculosis. Upon 

returning to the States, Lepreau worked 
with the impoverished in Appalachian 
mining towns and eventually founded a 
clinic for substance abusers in West- 
port, Massachusetts. The book charts 
not only the external events of a life, but 
also the interior evolution of a physician. 

The World According to Homo Sapiens 

by Philip R. Sullivan '57 (iUniverse, 2005) 

Sullivan, a psychiatrist and sheep farmer, 
probes what makes our experience of the 
world unique to our species. Philosophy, 
biology, particle physics, and Greek 
mythology commingle to shape the book's 
broad view of Homo sapiens. Divided into 
three parts, the book examines our phys- 
ical perception of the world, our applica- 
tion of values in making choices, and our 
consciousness of our experiences. 

Understanding Your Child's 

by William B. Carey '54 with Martha M. 
Jablow (Revised edition; The Children's 
Hospital of Philadelphia. 2005) 

One family, two kids, two temperaments. 
One child is a bold chatterbox; the other 
daydreams constantly. Carey's book helps 
parents and other caregivers recognize 
nine distinct traits that dictate how a 
child will interact with his environment, 
and thus, how temperament may affect a 
child's health, school performance, and 
development. The book is especially help 
ful for parents who want to understand 
their child's temperament in order to 
guide and meet the child's needs. 




Research Roundup 

Splitting the Difference 

Subtle differences in how a single 
gene behaves on opposite sides of the 
growing brain may explain how such 
talents as language, math skills, and 
imagination arise in specific sides of 
the brain in most people. 

According to Howard Hughes Med- 
ical Institute investigators Christopher A. 
Walsh and Tao Sun and their colleagues 
at Beth Israel Deaconess Medical Center 
and Harvard Medical School, the dis- 
covery that a gene called LM04 is 
expressed differently in the cerebral 
cortex in the left brain, compared to the 
right brain, may help explain how in 
most people one side of the brain 
achieves dominance over the other. A 
detailed report on their findings 
appears in the June 17 issue of Science. 

"This left/right asymmetry in the 
brain is an essential part of our human- 
ness ," Walsh says, "and learning how it 
comes about is important for under- 
standing where our human abilities 
came from." Perhaps more important, 
Walsh adds, this normal asymmetry of 

the brain is disrupted "in a host of 
human neurological diseases, such as 
schizophrenia. So this may offer us 
entry into how such problems relate to 
the development of the human brain." 

Magnetic Reaction 

A new therapy that uses magnetic 
pulses to stimulate the brain may 
improve recovery after a stroke, 
according to a study published in the 
May 24 issue of Neurology. The treat- 
ment, called repetitive transcranial 
magnetic stimulation, consists of a 
brief electrical current passed through 
an insulated wire coil placed on the 
scalp to create a magnetic pulse that 
stimulates the brain cortex. 

The study compared eight recent 
stroke victims who were relearning to 
use their affected hands with six people 
who had never had a stroke. Motor func 
tion in the affected hands of the stroke 
patients improved by as much as 50 per- 
cent on some of the tests; healthy volun 
teers exhibited no motor improvement. 

"These results are exciting because 
magnetic stimulation is a non- invasive, 
painless therapy that can be done while 
patients are awake," says study author 
Felipe Fregni, a physician at Beth Israel 
Deaconess Medical Center and an 
HMS instructor of neurology. "These 
results need to be confirmed by larger 
studies with more patients, but the 
results are encouraging." 

Q Calls 

Five years ago at Massachusetts General 
Hospital (MGH) the negative appen 
dectomy rate — which measures how 
often patients with symptoms of appen- 
dicitis have their appendix removed and 
are subsequently diagnosed as not hav- 
ing had acute appendicitis — was 20 per- 
cent, but since the advent of CT screen- 
ing for appendicitis, it has dropped to 3 
percent, say MGH researchers. 

"Prior to CT there was no way with- 
out surgery to be sure whether appen 
dicitis was present in most patients," 
says James Rhea, lead author of the study. 


experienced a heart attack remain at increased risk for sudden 
death after their discharge from the hospital. To better under- 
stand whom to treat and when, researchers at Brigham and 
Women's Hospital (BWH), in collaboration with an internation- 
al research team, studied sudden death among heart attack 
victims enrolled in the VALIANT trial (Valsartan in Acute 
Myocardial Infarction Trial). The study appears in the June 23 
issue of the New England Journal of Medicine. 

According to lead author Scott Solomon '86, director of non- 
invasive cardiology at BWH, given today's life-saving drugs 
and treatments, it is important to better understand the thresh- 
old of risk. "As we discharge patients earlier and earlier after 
heart attacks, we need to consider this risk. While we current- 
ly have good long-term therapies for patients at high risk for 
sudden death — notably, implantable defibrillators — the fact 


Subtle differences in how a single gene behaves on opposite 
sides of the growing brain may explain how such talents as 
language and math skills arise in specific sides of the brain. 

which appeared in the June 2005 issue of 
the American journal of Roentgenology. "In 
most patients CT will he helpful in decid 
ing whether to remove the appendix." 

Policing the Barrier 

Novel immune boosting therapy with a 
hematopoietic growth factor may reduce 
symptoms and improve the quality of life 
for people with Crohn's disease, accord 
ing to a team of researchers whose recent 
clinical trial findings appear in the N lay 26 
issue of the New England journal oj Medicine 
Crohn's disease, a chronic inflamma- 
tory disorder of the gastrointestinal 
tract, is currently treated with immuno- 
suppressive agents to reduce symptoms 
only; there is no known cure. But a new- 
understanding of the pathophysiology of 
the disease — specifically that the cause 
may be a defect in the intestinal innate 
immune system — led researchers to 
hypothesize that a failure in the defen 
sive barrier of phagocytic cells in the 
intestines may result in microbe expo 
sure and thus an enhanced inflammatory 

response, and that an immune enhancer 
could aid Crohn's patients. 

"We're encouraged that these results 
support this new understanding of 
Crohn's," says lead author Joshua 
Korzenik, co director of the Crohn's and 
Colitis Center at Massachusetts General 
Hospital, "and hope they will lead to a 
new treatment option for the disease." 

A Leap in the Right Direction 

A recent study showed that the protea- 
some inhibitor bortezomib (Velcade) is 
twice as good at treating multiple 
melanoma as a conventional medication. 
The report, by Dana-Farber Cancer 
Institute (DFCI) researchers and their 
colleagues, appears in the June 16 issue of 
the New England Journal of Medicine. 

The findings represent the first wave 
ol tangible benefits resulting from a mol- 
ecular understanding of how drugs work 
against disease. "These results pro\ide 
confirmation that bortezomib should be 
used at first relapse, and they provide a 
strong rationale for its use as an upfront 

therapy," says first author Paul Richard 
son, clinical director of the Jerome Lipper 
Multiple Myeloma Center at DFCI. 

Bortezomib can cripple myeloma that 
has become resistant to conventional 
treatment, and it seems to boost the 
power ol conventional therapies when 
given in combination. But, in a recurring 
scenario with the first generation of new, 
targeted therapies, myeloma cells 
become resistant to bortezomib. "It's a 
good drug," says Angela Dispenzieri, 
associate professor of medicine at the 
Mayo Clinic in Rochester, Minnesota. "It 
isn't the cure, but perhaps it will be part 
of the cure someday." ■ 

that this risk is very high early on, then declines, would sup- 
port the development of short-term strategies." 

Researchers studied 14,609 men and women with left ventric- 
ular dysfunction, heart failure, or both after heart attack to assess 
the incidence and timing of sudden unexpected death in relation 
to left ventricular ejection fraction. Causes of death were classi- 
fied as non-cardiovascular or cardiovascular, and cardiovascular 
deaths were further classified as sudden or due to heart attack, 
heart failure, stroke, or other cardiovascular causes. 

Of all the patients studied, 1 ,067 died suddenly or were 
resuscitated following a cardiac arrest (the median time after 
heart attack was 1 80 days). The risk of sudden death or car- 
diac arrest was highest in the first 30 days after heart attack. 
Indeed, during the first month, the rate of sudden death or 
cardiac arrest was 1 .4 percent; after two years, the rate 
dropped to one-tenth of that. Furthermore, most patients who 

died suddenly during the first 30 days did so after hospital 
discharge. Those with lower left ventricular ejection fraction, 
diabetes, and hypertension carried a higher risk of sudden 
death or cardiac arrest. 

According to the researchers, these data indicate that the 
risk of sudden death changes dynamically after a heart 
attack, and that even patients with higher ejection fraction 
may be at risk during this early period. Current guidelines rec- 
ommend implantation of a defibrillator for patients with signifi- 
cantly reduced left ventricular function after a heart attack, but 
not until at least 30 days after the event. During this period, 
many patients who remain at high risk are unprotected. 

"We need to consider therapies and strategies, even 
short-term bridging strategies," says Solomon, "that could 
protect patients during this early vulnerable period following 
a heart attack." ■ 





Not Sleeping Tight: Heart Tracings Reveal the Instability of Sleep 



the resting heart speeds up 
and slows down slightly with 
each breath in and out. But 
when the heart rhythm drops out of 
sync with breath-to-breath respiration, 
slumber becomes more fitful and tiring. 

Normally, a person must be wired 
and monitored from head to toe to 
assess sleep quality. An overnight sleep 
evaluation continuously tracks brain 
waves, eye movements, snoring, leg 
twitches, teeth grinding, and much 
more. Now, just one of the many trac- 
ings, a simple continuous electrocardio- 
gram (ECG), may be able to do the job of 
a suite of independent instruments, 
researchers at Beth Israel Deaconess 
Medical Center (BIDMC) report in the 
September issue of Sleep. 

'This is a distal but clean biomark- 
er that tells us if the system is oscillat- 
ing in synchrony with each breath or 
over multiple breaths," says first 
author Robert Thomas, head of the 
BIDMC sleep laboratory and HMS 
instructor in medicine. "This reflects 
stable and unstable sleep behavior. Dis- 
ease expands the unstable behavior of 
the system. The goal of treatment is to 
enhance the stable behavior." 

If validated by further studies, the 
ECG as a measure of sleep stability may 
be an easier and less expensive way of 
diagnosing and guiding the therapy of 
sleep disorders. 

The work also lends credence to a 
nonconventional way of thinking about 
the stages that make up most of a good 
night's sleep, known as non-rapid- 
eye-movement (non-REM) sleep. The 
researchers' ECG analysis revealed two 
states of non-REM sleep, stable and 
unstable. In contrast, the traditional 
staging system divides non-REM sleep 
into four grades ranging from light to 
deep sleep, which correlate with the 
effort needed to wake someone up. The 
sleep staging standards are now being 
reevaluated (see sidebar). 

The Heart of Sleep 

In overnight evaluations, multiple lines 
of data spike and plunge across a large 
computer screen in real time as the sec- 
onds and minutes pass. When one mea- 
surement changes — reflecting a gasp, a 
snore, or a shift in body position— most 
of the other markers change in syn- 
chrony. "A sleep study is like an orches- 
tral score of the music of the sleeping 
body," Thomas says. 

"The breathing and heart rate control 
turn out to have a profound connection to 
what's going on in the brain during sleep," 
says senior author Ary Goldberger, direc 
tor of the Margret and H. A. Rey Institute 
for Nonlinear Dynamics in Medicine at 
BIDMC and an HMS professor of medi 
cine. "It ratifies the growing consensus of 
the importance of cross talk and systems 
biology. You have one set of conversations 
going on between the heart and lungs and 
nervous system in health. In pathology. 

the frequency and tone of that conversa- 
tion literally changes and you see a new 
conversation emerge." 

Thomas began to wonder about non- 
REM sleep about five years ago. He was 
becoming both intrigued and frustrated 
by the spontaneous flips back and forth 
between stable and unstable patterns of 
sleep in patient after patient. Bad sleep 
could suddenly change to good and vice 
versa without any intervention and 
while remaining in the same grade of 
non-REM sleep. 

In the Land of Nod 

Brain waves are the gold standard in sleep 
medicine. Thomas noticed that the elec- 
troencephalogram patterns of these 
Jekyll and- Hyde sleep patterns had been 
described by a group of Italian researchers 
as cyclic alternating patterns (CAP) and 
non- cyclic alternating patterns (non- 
CAP). In several published studies, 


Thomas correlated the CAP/non-CAP to 
measurements of sleep quality and sleep 
disorders. Seeking an independent valida 
tion, he turned to Goldberger's group. 

Meanwhile, coauthor Joseph Mietus, 
a BIDMC bioengineer, had shelved an 
initially disappointing algorithm he had 
devised to deconstruct a single jagged 
ECG plot to show the link between the 
heart rate and breathing dynamics. He had 
hoped it would help diagnose sleep apnea, 
but he could not correlate his results 
with the classic non-REM sleep staging 
standards. Coauthor Chung-Kang "C. K." 
Peng, an HMS assistant professor of med- 
icine and co director of the Rey laborato- 
ry, thought the approach had promise and 
urged him to pursue it further. 

When Thomas first asked them for a 
mathematical way to distinguish between 
CAP and non CAP sleep in his sleep 

study datasets, Goldberger, Mietus, and 
Peng felt daunted by what they envi- 
sioned as an insolvable problem. 

But because Goldberger directs Phys- 
ioNet, a research resource funded by the 
National Institutes of Health, his group 
felt a responsibility to help Thomas, an 
NIH funded researcher. So Mietus ran a 
sample dataset through his algorithm, 
expecting it to be a dead end. 

"It turned out to be enormously excit 
ing," Goldberger says. They refined the 
technique with 70 sleep studies on 
patients from BIDMC and other accredit 
ed sleep centers. The stable and unstable 
sleep patterns overlapped with — but 
were not identical to — the CAP/non- 
CAP brain wave patterns. When the 
researchers retested the trained algorithm 
on data from 15 healthy people who were 
part of a different study, they discovered 

that stable and non-stable sleep were a 
feature of normal sleep in healthy people. 

Mietus devised a quick way to visual- 
ize the results using a "sleep spectrogram" 
with two distinct mountain-range bands. 
Healthy people show more stable sleep; 
people with untreated sleep disorders 
show more unstable sleep. The stable and 
unstable sleep patterns do not correlate 
with conventional non-REM sleep stag- 
ing, suggesting a complementary new 
view of sleep regulation and physiology. 

"We are not proposing a new sleep 
classification system," Thomas says. 
"We're saying this is how non-REM 
sleep works. The field can decide what to 
do with the new information and how to 
use this new tool." ■ 

Carol Cruzan Morton is a science writer 
for Focus. 


Imost 40 years ago, a dozen sleep scientists grew 
concerned about the reliability of the way they scored 
stages of sleep in their research. One weekend, they 
met to refine a set of standards for classifying the sleep 
cycle as wakefulness, rapid eye movement (REM), and non-REM. 
A major sticking point came in discussions about how to fur- 
ther classify the obvious variations in non-REM sleep. At one 
point during the extended debate, Allan Rechtschaffen from the 
University of Chicago, who coauthored the resulting manual, 
locked the door and declared that the scientists could not leave 
until they had reached a consensus. It was an empty threat, but it 
worked. They divided non-REM sleep into four stages known as 
arousal thresholds, which roughly correlate with the amount of 
shouting and shaking required to wake someone up. 

Published in 1968, the manual provided an important tool 
for modern sleep research. The rapidly expanding field of sleep 
medicine also relied on the manual, even though the supporting 
data were mostly based on observations of healthy people. 

"It gave people a language and a tool with which they could 
compare observations," says Wolfgang Schmidt-Novarro at the 
Sleep Medicine Institute at Presbyterian Hospital of Dallas, "but it 
doesn't do a particularly good job of providing insights or para- 
meters for diagnosing disease." 

For the first time, the manual is being revised to include more 
clinically relevant standards, such as the addition of respiratory 
and cardiac criteria. Extensive evidence from people with sleep 
disorders will underlie some of the changes. Where sufficient evi- 
dence does not exist, the reviewers will revert to consensus. 

The staging of non-REM sleep has remained problematic. The 
reworked manual is not scheduled for completion until the sum- 
mer of 2006, but it appears that the scoring of non-REM sleep 
may be compressed into three stages, says Conrad Iber of the 
University of Minnesota, who is heading the process for the 
American Academy of Sleep Medicine. 

Digital analyses, such as the new study by Robert Thomas and 
his colleagues at Beth Israel Deaconess Medical Center, will be 
considered, but the studies are probably too preliminary to be 
included in the new manual, Iber says. 

"It's missed that boat," Thomas says. "Maybe in the next 

The new standards will undergo review every five years, 
Iber says. In the meantime, Thomas has integrated the new 
knowledge into his clinical practice by more precisely tuning 
treatment to enhance stable sleep. And he and his colleagues 
have launched new studies to evaluate clinical correlates of 
stable and unstable sleep. ■ 







How can doctors avoid becoming white-coated cogs in the machinery of medicine? 


I WaS Stunned to receive the call requesting that I 
speak to your class, and I thank you for the unbelievable 
honor. Only ten years ago, I was sitting just where you are — 
right there, six rows back, a bit to the side — a graduate- 
to-be largely unaware of what I was getting myself into. 
Looking back, I think it was the numbers I was least pre- 
pared for. We are a nation with a population of more than 
296 million people. For these people — never mind the six 
and half billion others around the world — you today become 
but one of 819,000 U.S. physicians and surgeons. Also taking 
part in the effort to help people lead long, healthy lives are 
some 2.4 rnillion nurses, 388,000 medical assistants, 232,000 
pharmacists, 294,000 lab technicians, 121,000 paramedics, 
94,000 respiratory therapists, and 85,000 nutritionists. The 
numbers are incomprehensible. 

Now, a doctor is no bit player. You leave 
HMS with the power to prescribe any 
of more than 6,600 potentially danger 
ous drugs. You will be permitted to put 
needles, wires, and tubes into human 

beings and soon even to manipulate 
their DNA. Hundreds will depend on 
you personally for their lives and their 
happiness. This is the special function 
we, as doctors, get to serve in society. 

Yet, in the midst of this work, you will 
fast realize that you are still just part of 
a machine — an extraordinarily successful 
machine, but a machine nonetheless. 
How could it be otherwise? The average 
American can expect to live at least 78 
years — two years longer than when 1 
graduated. But reaching — and surpass- 
ing — that goal depends more on this sys- 
tem of hundreds of thousands of clinicians 
than on any one individual within it. 

So as you become a white-coated cog 
in this machine — this remarkable and, at 
the same time, maddening factory of 
health care — how do you not disappear? 
How do you matter? 

I'd like to offer five rules that may 
guide you in finding good answers to 
these questions. My rules for medical 
practice should be distinguished from 
the laws of medical practice. Rules are 
personal instructions you might follow 
in your life as a doctor. Laws are the 
immutable realities you come up against 
in that life. For example, one law is: The 
labs are always normal, the lumps are 


But what I want to talk about are SO Will IV U LJl 

thousands who make their lives in this strange and teeming world of 


never cancer, and the 16-year-olds are 
never pregnant — unless you fail to 
check. Or: If your new patient is on five 
or more drugs, you will not have heard of 
at least one of them. 

Many other laws exist. There are, for 
example, 35 laws governing the behavior 
of pagers alone. But what I want to talk 
about are some rules for how to survive 
among the hundreds of thousands who 
make their lives in this strange and 
teeming world of medicine — and, more- 
over, having survived, how to make a 
worthy difference. 

My Rule #1 for you comes 
m a favorite essay by the 
writer Paul Austen Ask an 
unscripted question. Ours is a job of talking 
to strangers. Why not learn something 
about them? 

On the surface, this seems easy 
enough. Then your new patient arrives. 
You still have three others to see and two 
pages to return, and the hour is getting 
late. In that instant, all you will want is 
to get things over with. Where's the pain, 
the lump, whatever it is? How long has it 
been there? Does anything make it better 
or worse? What are your past medical 
problems? You all know the drill. 

But I want you, at an appropriate 
point, to take a moment with your 
patient. Make yourself ask an unscripted 
question: "Where did you grow up?" Or: 
"What made you move to Boston?" Or: 
"Did you watch last night's Red Sox 
game?" You don't have to come up with a 
deep or important question, just one that 
lets you make a human connection. Some 
people won't be interested in making 
that connection. They'll just want you to 
look at the lump. That's okay. Look at the 
lump in that case. Do your job. 

You will find, however, that many 
respond — because they're polite, or 
friendly, or perhaps in need of that 
human contact. When this happens, see 
if you can keep the conversation going 
for more than two sentences. Listen. 

Make note of what you learn. This is not 
a 46-year-old male with a right inguinal 
hernia. This is a 46-year-old former mor- 
tician, who hated the funeral business, 
with a right inguinal hernia. 

You can do this with people other 
than patients, too. Ask a random ques- 
tion of the medical assistant who 
checks their vitals, the ICU nurse you 
see on rounds. It's not that making this 
connection necessarily helps anyone. 
But you will start to remember the peo- 
ple you see, instead of having them all 
blur together. And sometimes you will 
discover the unexpected. 

I learned, for instance, that an elderly 
Pakistani phlebotomist I saw every day 
during my residency had been a general 
surgeon in Karachi for 20 years, but 
emigrated for the sake of his children's 
education. I found out that a quiet, care- 
fully buttoned-down nurse I work with 
had once dated Jimi Hendrix. 

The machine will gradually feel less 
like a machine. 

Rule #2 is: Don't whine To be 
sure, doctors have plenty to 
complain about: computer sys- 
tem crashes, pre-dawn pages, insurance 
companies, work getting dumped on us at 
six o'clock on a Friday night. We all know 
what it feels like to be tired and beaten 
down. Yet nothing in medicine is more 
dispiriting than hearing doctors whine. 

Anyone who has played high school 
sports understands the dynamic I'm 
talking about. Morale is elusive and frag- 
ile. My southern Ohio hometown high 
school tennis team traveled up to 75 
miles through Appalachia for matches 
against other teams. We were undefeat- 
ed. But when the weather got hot, a few 
bad calls went against us, the matches 
grew close, and that long, un-air-condi 
tioned ride home began to loom, the 
griping would begin. It was all Coach 
Roach (that really was his name) could 
do to keep us from giving in to defeat. 
He'd stomp and yell, "What are you cry- 

babies bellyaching about?" Since he was 
also the school psychologist, we'd finally 
remember the reason we were there. 

The practice of medicine can go the 
same way. It is a team sport with two 
differences: the stakes are people's lives 
and we have no coaches. The latter is the 
most relevant difference. Doctors are 
supposed to coach themselves. We have 
no one but ourselves to buck us up. But 
we're not good at it. Wherever you find 
doctors — sitting with fellow residents in 
the hospital cafeteria, waiting in a con- 
ference hall for grand rounds to start — 
you will find the natural pull of conver- 
sational gravity is toward the litany of 
woes all around us. 

Resist it. It's boring, and it will get you 
down. You don't have to be sunny about 
everything. Just be prepared with some- 
thing else to talk about: an interesting 
patient you saw, an idea you read about, 
even the weather if that's all you've got. 

Then see if you can keep the conversa- 
tion going. 

Q Rule #3 is: Count something. No 
matter what you ultimately do 
in medicine — whether you go 
into purely clinical practice or work in 
research or business and never touch a 
patient again — a doctor should be a sci- 
entist in his or her world. In the simplest 
terms, this means we should count some- 
thing. The laboratory researcher may 
count the number of tumor cell lines 
with a particular gene defect. Likewise, 
the clinician might count the number of 
patients who develop a particular com- 
plication — or even just how many are 
seen on time and how many were made 
to wait. It doesn't really matter what you 
count. You don't need a research grant. 
The only requirement is that what you 
count should be interesting to you. 

When I was a resident I began count- 
ing how T often our surgical patients 
ended up with an instrument or sponge 
forgotten inside them. It didn't happen 
often: about one in 15,000 operations. But 



• -••-*. 

for how to survive among the hundreds of 
medicine — and, moreover, having survived, how 


when it did, serious injury could result. 
One patient had a 13-inch retractor Left in 
him, which tore into his bowel and blad- 
der. Another had a small sponge left in 
his brain, which caused an abscess and 
permanent seizure disorder. 

Then I counted how often such mis 
takes occurred because the nurses had- 
n't counted all the sponges like they 
were supposed to, or because the doc- 
tors had ignored nurses' warnings that 
an item was missing. It turned out to be 
hardly ever. 

Then I got a little more sophisticated 
and compared patients who had objects 
left inside them with those who didn't. 
It turned out that the mishaps predom 
inantly occurred in patients undergoing 
emergency operations or procedures 
that revealed the unexpected — like a 
cancer when the surgeon had anticipat 
ed only appendicitis. 

The numbers began to make sense It 
nurses have to track 50 sponges and a 
couple hundred instruments during an 
operation — already a tricky thing to 
do — it is understandably much harder 
under urgent circumstances, or when 
unexpected changes require bringing in 
lots more equipment. Punishing people 
wasn't going to eliminate the problem. 
Only a technological solution would — 
perhaps a way of scanning for sponges 
and instruments in everyone. 

If you count something you find 
interesting, you will learn something 

Rule #4 is: Write something. It 
makes no difference whether 
you write a paper for a medical 
journal, five paragraphs for a website, or 
a collection of poetry. Try to get your 
name in print at least once a year. What 
you write need not achieve perfection. It 
needs only to add some small observa- 
tion about our world. 

One should not underestimate the 
effect of one's contributions. As the 
physicist John Ziman once pointed out. 

"The invention of a mechanism for the 
systematic publication of 'fragments' of 
scientific work may well have been the 
key event in the history of modern sci- 
ence." By soliciting modest contribu 
tions from the many, we have produced 
a store of collective know-how with far 
greater power than any one individual 
could have achieved. This is as true out- 
side science as inside. 

One should also not underestimate 
the power of the act of writing itself. I 
did not write until I became a doctor. 
But once I became a doctor, I found I 
needed to write. Medicine is retail. We 
provide our services to one person at a 
time, one after another. It is a grind. For 
all its complexity, it is more physically 
than intellectually taxing. But writing 
let me step back, engage as more than a 
retailer, and think through a problem. 
Even the angriest rant forces the writer 
to achieve a degree of thoughtlulness. 

Furthermore, by offering your writ- 
ing to an audience, even a small one, 
you connect yourself to something larg- 
er than yourself. The first work I ever 
published, in an online magazine, was a 
diary of five days as a surgical resident. 
I remember my reaction after the piece 
came out. I was proud but also nervous. 
Would people notice it? What would 
they think? Did I say something dumb? 
An audience is a community. The pub 
lished word is a declaration of member 
ship in that community and also ot the 
desire to contribute something mean 
ingful to it. 

So choose your audience. Then write 

, Rule #5, my final rule ior a 
good life in medicine, is: 
Change. In medicine, as in any 
human endeavor, people respond to 
new ideas in one of three ways. A few 
become early adopters, as the business- 
types call them. Most become late 
adopters. And some remain persistent 
skeptics, who never stop resisting. A 

doctor has good reasons to adopt any of 
these stances. When Joseph Murray '43B 
and Francis Moore '39 performed the 
world's first successful kidney trans- 
plant 50 years ago after 30 deaths, when 
a French gynecologist first pointed his 
laparoscope in a new direction and used 
it to take out a gallbladder, when cho- 
lesterol-lowering drugs first came out, 
when the first electronic medical 
record was invented — who was to say 
whether these were truly good ideas? 
We have seen plenty of bad ones. 
Frontal lobotomies were once per- 
formed to control chronic pain. Vioxx 
turns out to cause heart attacks. 
Viagra, it was recently discovered, may 
cause partial vision loss. 

Nonetheless, make yourself an early 
adopter. Look for the opportunity to 
change. I am not saying you should 
embrace every new trend that comes 
along. But be willing to recognize the 
inadequacies in what we do and to seek 
out solutions. As successful as medicine 
is, it remains replete with uncertainties 
and failure. This is what makes it human, 
at times painful, and so worthwhile. 

You become doctors today, and the 
choices you make with your patients 
will be imperfect but will nonetheless 
alter their lives. There will come a time 
when, because of that reality, it seems 
safest to do what everyone else is 
doing — to be just another white-coated 
cog in the machine. 

Don't let yourself be. Find something 
new to try, something to change. 
Count how often you succeed and how 
often you fail. Write about it. Ask a 
patient or a colleague what they think 
about it. See if you can keep the con 
versation going. ■ 

Atul Gawandc % 94 is a surgeon at Brigham 
and Women's Hospital, an assistant professor 
of surgery at HMS, an assistant professor of 
health policy and management at the Harvard 
School of Public Health, and a staff writer for 
The New Yorker. 


BACK* the 


A young physician's lighthearted take on an imaginary medical 
forbear highlights the timeless nature of the School's mission. 

In 3. ICW SilOrt hours, we will launch our careers as 
physicians, researchers, and — for those of us who erred in fill- 
ing out our match forms — respiratory therapists. And while 
graduation day is very much about looking at our future, we 
must also ponder the past and realize that we are joining 
an unbroken chain of HMS graduates now stretching back 
nearly 225 years. I was reminded of this point yesterday 
when I came across a fascinating building. You would think 
that after four years at HMS I would know everything about 
my own campus. But just 24 hours ago, I stumbled upon a 
remarkable structure that houses physical versions of the 
medical books and journals I read online. It is called the 
Countway Library of Medicine. 

In the basement of this mysterious 
building, I unearthed the secret diary of 
a Harvard Medical School student from 
the Class of 1795— John Warren, Jr. 
Reading the words John penned so many 
years ago has convinced me that many of 
the experiences that marked our days at 
HMS are indeed timeless. 

Do you remember the excitement of 
receiving your HMS acceptance letter? 

Well, consider John's entry dated March 3, 
1791: "Dear Diary: I am so excited! 1 have 
just found out I was selected to attend 
the new medical school at Harvard. It is 
certainly the more prestigious of the two 
American medical schools in existence. 
Perhaps now that I am a Harvard man, 
girls will finally like me." Or his entry 
from just a few days later: "Dear Diary: 
'Twas a false hope — I remain lonely." 

For the Class of 2005, our first year 
was a blur: from anatomy to microbiolo- 
gy to Patient/ Doctor I, we were trans- 
fixed by our first exposure to medicine. 
I believe John was expressing a similar 
sentiment in his entry from May 6, 
1792: "Dear Diary: First year has been 
such a blur. I am enjoying all of my 
classes, from neurocarpentry to advanced 
bloodletting. Especially crucial has been 
Patient/ Doctor I, in which I am learning 
to communicate with my broad range of 
patients, from the white Episcopalians 
of the North Shore to the white Lutherans 
of the South Shore." 

Let me skip a bit ahead here, so we 
can see what John had to say about life 
on the wards. This entry is dated 
October 12, 1793: "Dear Diary: My med- 
icine resident says I have the option to 
give a five- minute presentation to the 
team on the topic of my choice. But I 
wonder: Is it really optional? If it is not 
optional, should 1 make a handout? If I 
make a handout, should I tell the other 
students that I will be making a hand- 
out, or should I just surprise them with 
it?" Yep, pretty much the same as 
it is today. 





I also discovered an entry dated June 9, 
1795, which I found particularly relevant 
to us at these commencement exercises: 
"Dear Diary: Graduation day has arrived! 
My whole family has made the six-hour 
journey — from Brighton. I am excited but 
apprehensive about what lies ahead. 
There are high expectations for Harvard 
Medical School graduates, and I hope 1 
can live up to them." 

Indeed, truer words have never been 
written in a phony diary. Our predeces- 
sors have taken the training they 
received here and gone on to produce 
amazing work as healers, researchers, 
and champions of social justice. HMS 
graduates have included legends in the 
history of medicine, such as Harvey 
Cushing, Class of 1895, the father of mod 
ern neurosurgery, as well as more recent 
physician stars, such as Paul Farmer '90, 
founding director of Partners in Health, 
an international organization that advo 
cates for those who are sick and living 
in poverty. With such a pantheon of 
pioneers preceding us, those of us here 
today in black robes might well be a 
little nervous. 

But instead we should celebrate our 
connection to other graduates — young 
and old, current and past, fictional and 
real — who have forged their medical 
development in the crucible of these 
same halls through which we have had 
the privilege to walk during the past 
few years. We are entering a special 
community of HMS alumni. Let this 
community be a fount of strength in the 
years to come, not a source of intimida- 
tion. Let the successes of our forebears 
challenge and inspire us. 

No matter where you go from 
here — whether it's the Brigham, Mass 
General, or the Brigham — never forget 
your time on this campus. Because 
from the Class of 1795 to the Class of 
2005, Harvard Medical School has 
been turning out passionate, caring 
physicians for more than 200 years, 
and now it is our turn to make sure 
that it will do so for the next 200 
as well. ■ 

jarcd Kesselheim '05 is a resident in internal 
medicine at Massachusetts General Hospital. 





A new graduate appreciates the good fortune that led him to 

F E D M A N 

It iS an honor to speak on behalf of the most 
extraordinary collection of financial debt assembled since 
the Reagan era — the Harvard Medical School Class of 2005. 
By some estimates, the amount our class owes the federal 
government is about the same as what the federal government 
owes the European Union. So in the spirit of patriotism Pd 
like to propose that the United States deploy the Class of 
2005 to Ibiza and the Riviera, and we'll just call it even. 

On this day, you will be tempted to offer 
us congratulations. But the fact that we 
will be walking across this stage testi- 
fies to one truth, and one truth only: 
that none of us graduating today pos- 
sessed the dedication, the creativity, the 
persistence, or the strength of character 
it would have taken to flunk out of 
Harvard once it let us in. 

After four years of study, I have 
learned the following: that most adoles- 
cents in pediatric clinics have more 
active sex lives than I do; that surgeons 
might not know what an organ does, 
but they aren't afraid to take it out; that 
PowerPoint is the most efficient way to 
make a presentation — because it saved 

our professors the trouble of thinking 
about their lectures and us the trouble 
of remembering them; that we will 
struggle for years to attain a white coat 
the same length as the one the guy from 
food service receives immediately; and 
that there is no situation in the hospital 
so hopeless that a Harvard medical stu- 
dent can't make it worse. 

You probably think that you're here 
today to celebrate us, but we think that 
we're actually here to celebrate you — 
the family and faculty who got us to 
graduation. My parents, brother, and 
sister are here from Chicago — which my 
Harvard professors tell me is a small 
city located somewhere in California. 

My father is an internist who still 
loves going to the office after 40 years in 
practice. Like many of the physician- 
parents in the audience, Dad was mildly 
horrified that his child decided to go to 
medical school in the current health care 
climate; but he and my mother — the best 
teacher I know — have always supported 
our right to make our own mistakes. 

Since they'll be watching this on 
video, I want to say the following to my 
grandparents: if you'd had one- quarter of 
the opportunities that you and my par- 
ents struggled to give me, you'd have 
been standing on this stage 60 years ago. 
So I'd like to take this chance to thank 
my family, and all the families here, 
who worked so hard to give us the 
choices we've had. And for 
those of you who were 
able to pay your child's 
tuition outright: i 
hope you feel good 
about having pur- 
chased an education 
instead of, say, the 
Cayman Islands. 

Great teaching often 
occurs when no one is 





watching, with no expectation of recogni 
tion or reward, which is precisely why I'd 
like to mention a few of the faculty who 
were tremendously kind to me. Academy 
Award style, let me briefly thank the fol- 
lowing: my surgical mentors — David 
Soybel, Ronald Bleday, and Richard 
Hodin — as well as Nancy Oriol 79, Allan 
Goroll 72, Gordon Strewler, Jr. 71, Julian 
Seifter, and Cindi McDermott. I'd also like 
to thank the surgeon in chief at Brigham 
and Women's Hospital, Michael Jeffrey 
Zinner, who made time to meet with us 
every week when we were third years; and 
Charles McCabe, a surgeon who trained 
one-third of my class and probably one 
half of the residents in this audience. 

And I am particularly 
delighted that our gradu 
ation speaker is Atul 
Gawande '94, who, in addi 
tion to being a busy sur 
geon and elegant writer, lound time to 
encourage me to pursue my interests in 
surgery and international medicine. 
We're aware that our mentors could 
have been spending more time with their 
patients, their families, or their research. 
Instead, they chose to spend some of 
it with us, we are profoundly 
grateful, and we prom 
ise not to tell their 

Perhaps the most extraordinary con- 
tribution to our education, however, 
came from the thousands of patients who 
allowed us to learn from them so we 
could someday treat others. I'll never for- 
get the elderly female patient who once 
told me: "You remind me of my husband. 
You don't look like anything like him, 
though. He was a very handsome man." 

But there were serious lessons, too, of 
course. From classmates like Kedar, Nupe, 
\laryCatherine, and Laura — whose work 
in clinics around the globe inspired my 
interest in international medicine — I 
learned the simple proposition that our 
neighbors in the world should be treated 
like neighbors. Because of their contribu 
tions, patients in Haiti, Guatemala, Africa, 
and Asia know that our country has far, 
far more to offer the world than guns, 
pharmaceuticals, and arrogance. 

I have also learned that we may never 
match the intellectual accomplish 
ments of our professors, but il we 
rigorously abstain from exer 
cise, we might some 
day match their 

But the most valuable lesson is the 
one my roommate learned while watch- 
ing an anesthesiologist save someone's 
life during a code by injecting just the 
right medication — into a patient he 
thought was the patient next door. You 
can read about this incident in Atul 
Gawande's upcoming book. Your Hospital 
Is Trying to Kill You. The lesson is simple: 
in medicine, as in life, it's far more 
important to be lucky than to be good. 

My friends and classmates, we've 
spent the last four, five, or — in some 
cases — thirty-seven difficult years of our 
lives studying to get good, and not one of 
us graduating today can effectively treat 
lower back pain. So as we move forward 
into our residencies, let us resolve to 
take the focus off getting good and con- 
centrate instead on getting lucky. ■ 

Gregory Fcldman '05 is a resident in general 
surgerx m the Stanford University Programs. 

1> M i 

■• rr. 


Today, you stand before family 
friends, teachers, and colleagues 
as newly appointed physicians. 
For two thousand five hundred 
years, since the time of Hip- 
pocrates, doctors have taken an 
oath to affirm a commitment to 
their profession. This oath has 
served as both a tribute to their 
teachers and a contract with 
their community. I now invite 
you, as a class, to articulate 
the ideals and principles that 
will guide you in your journey 
as physicians. 


The following medical degree recipients 
graduated with honors or special awards: 

Francis Joseph Alenghat 

James Tolbert Shipley Prize for 
excellence and accomplishment in 
research: Global Cytoskeletal Control 
of Mechanotransduction in Kidney 
Epithelial Cells 


Oni Jahi Blackstock, Uche Abebe 
Blackstoclc, Karimi Grace Mailutha, 
Alanna Amyre Morris, Enyinnaya Rose 
Nwaneri, and Hien Thanh Tran 

The Multiculruralism Award to the 
senior in each academic society who 

I pledge, by all that I hold most sacred, to uphold this oath to the best of my ability and judgment. 

To My Patients: 

I vow to care for those in need and strive to alleviate suffering. 

I will care for a human being not simply treat a disease. 

I will deliver the highest quality medical care possible to all of my patients. 

I will remember that medicine is both an art and an ever evolving science in 

which warmth, honesty, and understanding complement the surgeons knife 

and the chemist's drug. 
I will empower my patients to make sound decisions for their health and well being. 
I will recognize the importance of my patients' spiritual beliefs and social situations. 
I will respect my patients' dignity and autonomy, both in living and in dying. 
I will honor and protect the confidences entrusted to me. 

To My Community: 

I embrace my duty to strengthen our society. 

I will work to promote health and prevent disease. 

I will pursue equality and justice in the delivery of health care. 

I will strive to overcome the social, economic, and environmental problems impacting the 

health of my patients. 
I will be aware of my actions and behaviors, knowing that as a physician I will be a role 

model to those around me. 

To My Colleagues: 

I promise to maintain the integrity and traditions of my profession. 

1 will respect the wisdom of my teachers and share this knowledge with my students. 

I will build upon and advance the art and science of medicine with honesty, kindness, and 

I will respect and collaborate with my fellow health care practitioners in order to provide 

the highest standards of patient care. 
I will not be ashamed to say, "I do not know." and will call upon others when needed for my 

patients' well being. 

To Myself: 

I remain ever mindful of the high ideals for which I chose to dedicate myself to medicine. 
I will ensure that the health of my patients is my priority. 
I will remain alert and competent by constantly improving my knowledge and skills. 
I will keep watch that my ambition and curiosity serve my patients and not my ego. 
I will recognize my limitations with humility. 

I will maintain and invest in my own health and well being so that I may best fulfill my 

\\ ith the support oj family, friends, and colleagues, I bear these responsibilities for the service 
of humanity. 



has done the most to exemplify and/or 
promote the spirit and practice of 
multiculturalism and diversity 

Eduardo Angel Borquez 

Society for Academic Emergency 
Medicine Excellence in Emergency 
Medicine Award to a senior medical 
student who has demonstrated excellence 
in the specialty of emergency medicine 

Martin Damien Burke 

Henry Asbury Christian Award for notable 
scholarship in studies or research: 
Generating Diverse Skeletons of Small 
Molecules Combinatorially 

Ann Lee Chang 

The Leonard Tow Humanism in Medicine 
Award presented by The Arnold P. Gold 
Foundation to a graduating medical 
student who consistently demonstrates 
compassion and empathy in the delivery 
of care to patients 

Andrew Eugene Hermann Elia 

Kurt Isselbacher Prize to the senior demon- 
strating humanitarian values and dedication 
to science; Leon Reznick Memorial Prize for 
excellence and accomplishment in research: 
The Molecular Basis for Phosphodependent 
Substrate Targeting and Regulation of Plks 
by the Polo-Box Domain 

Loretta Erhunmwunsee, magna cum laude 
Regulation of Ladybird Homeobox Gene 
Lbx I by Pax3 and Sox 1 1 

Christina Wilbert Fidkowski, cum laude 
Endothelialized Microvasculature Based 
on a Biodegradable Elastomer 

Hannah K. Galvin 

The New England Pediatric Society Prize 
to the senior who, in the opinion of peers 
and faculty, best exemplifies those quali- 
ties one looks for in a pediatrician 

Grant Edward Garrigues, cum laude 
Osteolysis and Aseptic Loosening of Joint 
Arthroplasty: Gene Expression in 
Cell-Biomaterial Interactions 

Jeremy Alan Greene 

Richard C. Cabot Prize for the best paper 
on medical education or medical history: 
Therapeutic Infidelities: "Noncompliance" 
Enters the Medical Literature, 1 955- 1 975 

Reena Gupta 

Robert H. Ebert Primary Care Achievement 
Award for excellence and outstanding 
accomplishments in the field of 
primary care medicine 

Catherine Jean Livingston, cum laude 
A Comparative Survey of Physicians' 
and Herbalists' Perspectives on the Use, 
Safety, Quality, Clinical Practice, and 
Regulation of Herbal Therapies and Dietary 
Supplements in New South Wales, Australia 

Shana Erin McCormack, 

magna cum laude 
Neural Correlates of Sleepiness: A 
Functional Magnetic Resonance Imaging 
Study of Sleep Deprivation and Sleep Inertia 

Gabrielle Page-Wilson, cum laude 
Prolactin-lnduced GnRH Suppression: 
Insight into the Mechanism of Lactational 

David Edward Rosow, cum laude 
Sonic Hedgehog: An Initiator, 
Maintenance Factor, and Potential 
Therapeutic Target in Pancreatic Cancer 

Sarah LaBree Russell 

Bemy Jelin '91 Prize to that senior 
who most demonstrates overall academic 
excellence with a career interest in 
pediatrics, oncology, international 
health, or psychiatry 

Joel Dov Sawady 

The Community Service Award to the 
senior who has done the most to exemplify 
and/or promote the spirit and practice or 
community service 

Joshua Marc Shulman, summa cum laude 
Genetic Modifiers of Neurodegeneration 
in a Drosophila Model of Tauopathy; 
Dr. Sirgay Sanger Award for excellence 
and accomplishment in research, clinical 
investigation, or scholarship in psychiatry 

Parmanand Singh 

The Gerald S. Foster Award in recognition 
of contributions to the student body by 
virtue of serving on a student-faculty 
committee, including, but not limited to, 
the Committee on Admission 

Kurt Arnold Smith, cum laude 
Adaptation of the Human Circadian 
Pacemaker to Prior Photic History 

Annemarie Stroustrup Smith, 

magna cum laude 

Fetal Magnetic Resonance Imaging in the 
Antenatal Diagnosis of Congenital Anom- 
alies; PASTEUR Award presented to a 
graduating medical student whose work 
best exemplifies clinical investigation that 
has resulted in a published paper or one 
accepted for publication: MR Imaging of 
the Fetal Skull, Face, and Neck 

Vladimir Vinarsky, magna cum laude 
Matrix Metalloproteinases and Tissue 
Inhibitor of Metalloproteinases in Newt 
Limb Regeneration 

Nikhil Wagle, cum laude 

The Role of Replication Protein CDC6 in 

DNA Damage Checkpoint Activation 

Sierra Mariposa Li'en Washington 

Rose Seegal Prize for the best paper on 
the relation of the medical profession to 
the community: PEPFAR in Zambia: The 
Rapid Scale-up of Anti-Retroviral Therapy 
in Lusaka, Zambia 

Benjamin Alden White, cum laude 
Creation of an Evaluation Matrix to 
Measure the Quality and Cost of 
Short-Term Medical Missions 

Susan Xiuqing Zhao, magna cum laude 
Suppression of Calcium-Induced Cardiac 
Electrical Instability as a Basis for 
Nitroglycerin's Antifibrillatory Action 

Hao Zhu, magna cum laude 

James Tolbert Shipley Prize for excellence 

and accomplishment in research: 

A Functional Analysis of Hematopoiesis 

and Vasculogenesis in Zebrafish Using a 

lmo2-EGFP Transgenic System 


with our 


Technologically correct medicine cannot trump the 
primacy of the bond between physicians and patients. 

BY ^ M A K 


1 3.rriVCCl clt medical school motivated to le 
how to care for patients and left filled with the notion 
that redemption lay, at a minimum, in the worlds of 
V specialty medicine and allied research. Worthy as 
these paths are, I ended up choosing another: that of 
the clinician-teacher within the world of adult pri- 
mary care medicine. My own journey along that clinical 
path has spoken to the moving, difficult, and sustaining 
reality of caring for — and learning from — patients. 





There are countless instances when a glance! 



When Anatole Broyard, described in The 
New Yorker as that "famously prickly book 
critic for the New York Times" wrote about 
his struggle with prostate cancer, he 
described what he sought in a doctor: 
"one who is a close reader of illness and a 
good critic of medicine.. .but a bit of a 
metaphysician too... [one who is able to] 
imagine the aloneness of the critically ill. 
I want him to be my Virgil, leading me 
through my purgatory or inferno, point- 
ing out the sights as we go." 

A guide. Given the oft-cited root 
meaning of "doctor" as "teacher" and 
"patient" as "sufferer," the details of that 
commingled journey reflect the cadence 
of each — a rhythm at times synchro- 
nous, at times chaotic, but at all times 
undeniably a joint pilgrimage. Rita 
Charon 78, an English scholar and pro- 
fessor of internal medicine, speaks of 
physicians as "gatekeepers to the land of 
the living." She reminds us of author 
Susan Sontag's view that there is "the 
kingdom of the well" and "the kingdom 
of the sick" and that "everyone who is 
born holds dual citizenship." According 
to Sontag, "Illness is the night-side of 
life, a more onerous citizenship," and 
physicians — because we know about 
that territory — are the guides for those 
who travel in the kingdom of the sick. 

The psychoanalyst Michael Balint 
reminds us that the physician and patient 
are coauthors of a single story, jointly con- 
structed. We are, after all, wired for 
stories, which demand to be heard. The 
beginning student of medicine soon 
learns how real and deep this need is. 

As Broyard puts it: "The patient has 
to start by treating his illness, not as a 
disaster.. .but as a narrative, a story. 
Stories are antibodies against illness 
and pain." In our patients' world, elicit- 
ing and understanding their stories lies 
at the core of what Charon calls narra- 
tive medicine. To be proficient here, 
Charon tells us, requires the "narrative recognize, absorb, inter- 
prc. ind be moved by the stories one 

hears or reads." This expertise "gives the 
doctor not only the means to under- 
stand the patient, but fresh means to 
understand the disease itself." The real- 
ity is, in Charon's words, that "scientifi- 
cally competent medicine alone cannot 
help a patient grapple with loss of 
health or find meaning in suffering." 

The argument is not, of course, about 
the insistence — by society as well as 
ourselves — that we must be scientifi- 
cally skilled. As physicians, we must 
learn to manage common occurrences 
uncommonly well and to recognize and 
triage the cannot-miss items in medi- 
cine filled with their own potential for 
severe morbidity and death. The demand 
here is the ear for another dimension, a 
recognition of the nonverbal, the accept- 
ance of a redirected agenda that may 
appear unexpectedly. 

Many years ago, after a long office 
visit with a patient who happened to be 
a physician, I said, "We've talked about 
many things, but before we proceed to 
the exam, is there anything else we 
ought to discuss?" 

"Yes," was the reply after a fleeting 
pause, "I've been thinking about sui- 
cide." And so our session had now real- 
ly begun. 

The dramatic elements of this story 
aside, there are countless instances 
when a glance, a moment's hesitancy, 
perhaps a tear, signals the emotional, 
pivotal moment in the clinical inter- 
view, which must be seized because it 
may never return. I like the late C. 
Roland Christensen's teaching point: 
"Listening is an audiovisual exercise" — 
which he nestled in the Swiss proverb 
that claims: "If you shut one eye, you do 
not hear everything." 

Abraham Verghese, a talented physi- 
cian-writer, reminds us that "as physi- 
cians, most of us become involved in the 
stories of our patients' lives. Sometimes 
we are simply witnesses.... But often we 
become players..." He tells a story, taken 
from Troyat's biography of the writer 

and physician Anton Chekhov, which 
illustrates this clearly. In the final days 
of his life, before he died young of tuber 
culosis, Chekhov traveled to a spa near 
the Black Forest in Germany. As his 
condition deteriorated, he sought the 
care of the spa physician, Dr. S.: 

The windows were wide open, but 
[Chekhov] could not stop panting; 
his temples were bathed in sweat. 
Dr. S. arrived at two o'clock. When 
Chekhov saw him, he sat up, leaned 
back against the pillows, and, in a 
final reflex of courtesy, mastered 
his weak German and said, "I am 
dying." Dr. S. immediately gave him 
a camphor injection, but his heart 
failed to react. He was about to 
send for an oxygen pillow when 
Chekhov, lucid to the end, protested 
in a broken voice, "What's the use? 
Before it arrives, I'll be a corpse." 
So Dr. S. sent for a bottle of cham- 
pagne. When it came, Chekhov 
took a glass and, turning to Olga 
[his wife], said with a smile, "It's 
been so long since I've had cham- 
pagne." He emptied the glass slowly 
and lay down on his left side. A few 
moments later he stopped breath 
ing. He had passed from life to 
death with characteristic simplicity. 

What an extraordinary act! We 
could parse its meaning on many levels, 
not the least of which is the challenge 
of caring for physicians given our col- 
lective need for control, our refined 
sense of denial, and our ease of self- 
diagnosis and treatment. 

In the context of a broader picture, 
however, the care of the dying repre- 
sents in its own intimacy an opportuni- 
ty for the richest expression of what we 
do as physicians. It is a time to bring to 
bear our best skills in the service of pain 
relief and the preservation of dignity. 
It is a time to recognize suffering as 
physician Eric Cassell has so persuasively 




a moment's hesitancy, perhaps a tear, 
VIOMENT in the clinical interview, 

written we must. It is a time when the 
physician as therapy trumps the physi- 
cian as therapist: when the most power 
ful form of our communication with 
patients finds expression in simply 
being there, in giving witness. And. it is 
a privileged reality to see the power of 
the love of others surround this suffer- 
ing and help to ease it. 

The fundamental transaction between 
patient and physician is represented by 
communication rooted in sharing, listen 
ing, and the reconciliation of different 
agendas. How much evidence-submit 
ted-in proof do we need to show that 
when this doesn't occur, trouble and 
disaffection follow? 

These are not new points, but we 
have fashioned a pernicious mismatch in 

which we proclaim that our students 
must appreciate the centrality of effec 
tive dialogue between patient and doc- 
tor, and then we place those students 
in a world in which this expression is 
unwelcome and suppressed. A world in 
which senior role models are often 
absent, and junior faculty and housestaff 
are forced to function in survival mode, 
which admits only to the facts. Context 
is nice, the argument goes, but function 
ally superfluous — or so it seems. 

The template for effective relation- 
ships is clear: establish trust, be techni- 
cally competent, listen for the story, be 
curious, care above all. I especially like 
this matter of bringing one's curiosity to 
the clinical transaction (I am reminded 
of Alan Gregg's observation that 'A 

good education should leave much to 

be desired"); if so, we ought to get about 

the business of measuring the curiosity 

titer in our students and in ourselves. 

Faith Fitzgerald, a brilliant diagnosti- 
cs o 

cian and teacher, offers this reflection 
from her own experience as a young 
attending at San Francisco General 
Hospital. Determined to prove to house- 
staff inclined to focus on the "interest- 
ing" patients at morning rounds that 
there was no such thing as an uninterest- 
ing patient, Fitzgerald requested the 
chief resident to identify the dullest. 

The resident selected an elderly 
woman who had been admitted to the 
hospital as an act of mercy because she 
had nowhere else to turn after eviction 
from her home. Gamely attempting to 




The unreasonable man 


elicit some good stories at the patient's 
bedside, Fitzgerald found hcrsell stymied 
by the old woman's monosyllabic- 
answers. "Nothing, it seemed, had ever 
really happened to her," Fitzgerald 
found herself on the verge of conceding. 
"She had lived a singularly unexciting 
life." And then she asked the woman 
how long she had lived in San Francisco: 

Years and years, she said. 

Was she here for the earthquake? 

No, she came after. 

Where did she come from? 


When did she come? 


Had she ever been to a hospital 



How did that happen? 

Well, she had broken her arm. 

How had she broken her arm? 

A trunk fell on it. 

A trunk? 


What kind of trunk? 

A steamer trunk. 

How did that happen? 

The boat lurched. 

The boat? 

The boat that was carrying her to 


Why did the boat lurch? 

It hit the iceberg. 

Now, the Review of Systems is nice, 
but when served up with a curiosity 
about the patient's world, it offers 
vital — indeed necessary — insight into 
the life context of patients, as well as 
an opportunity to advance one's own 
understanding of the world. Where 
else, but from one's practice, can one 
learn: how to boil an egg? (from a 
chef); theories about black holes (from 
an astrophysicist); how to judge the 
competence of a bricklayer (from a 
foreman); how a string quartet can 
provide insight into the teaching of 
teamwork (from a violinist); and how 
the Great Depression played out in the 
steel mills of the Midwest (from a 
foundry worker)? 

As one learns, history taking is an 
extended affair and over the years it 
reveals so much about the patient and 
about ourselves as well. These narra- 
tives help us recognize that which 
gives us joy in the practice of medicine. 

In these stories we have seen joy, 
courage, pain, suffering, enlightenment, 
humility, poignancy, loss, death, love, 
and privilege. All these narratives acquire 
their meaning from a broader context 
fashioned from the life journey of the 
patient and the caring physician. 
Context here is the coin of the realm. 

Richard Weinberg made this point 
brilliantly in his story "The Laying On 
of Hands," published over a decade ago. 

It is a story about the diagnosis, treat- 
ment, and "salvage therapy" for his 
brother's aggressive lymphoma — and 
about Weinberg's increasingly frenetic 
attempts to help in his care from a dis- 
tance. In this context Weinberg began 
to have chest pain for which he sought 
increasing amounts of corridor consul- 
tation: an after- hours negative exercise 
test courtesy of a weighed-upon car 
diac fellow, a self ordered chest film 
read as showing a mediastinum per- 
haps a bit generous in size, and finally 
making his own peripheral smear — the 
artifacts of which yielded leukemia- 
flavored panic. 

His chest pain escalated and domi 
nated his world until, at last, he sought 
out a well-respected clinician, a 
Dr. Davidson. This doctor was not, in 
Weinberg's words, "a rising star" in the 
department, but the go-to physician 
when illness struck. Davidson quickly 
agreed to see Weinberg in his office 
where the "whole sorry tale of [his] 
chest pain and [his] brother's illness" 
was revealed. The rest of the history 
was elicited and the exam completed 
when Weinberg, while getting dressed, 
with heart pounding and mouth dry, 
asked of Davidson: 

"Do we need any tests?" 

"No, I'd say you've done a pretty 

good job of that." 

"Then you know what's wrong?" 

"Yes, I think I do." 

"Is it lymphoma?" I choked out, fear 

ing the worst. 

"No, your lymph nodes feel normal 

to me and given the way you've been 

poking at them, it's no wonder 

they're a bit tender." 

"My heart..." 

"Your heart is fine." 



"Are you telling me that I'm imagin 

ing all of this?" 

"No. The pain is real." 

IMSELF to the world, 
persists in trying to adapt the world to himself. 


"Then what's wrong with me? 

What's causing the pain?" 1 


"You have heartache/' 

"Heartache?" The word struck me 

like a slap to the face. 

Davidson went on to explain: "Your 
brother is seriously ill. You are his best 
friend, and you've served as his person- 
al physician as well. You've helped 
guide him to the best treatment, com- 
forted him during the tough times, and 
given him the strength to go on. You've 
had to be strong for him and for your 
family. Now things don't look so good, 
you know the prognosis of his condi- 
tion, and you fear what is to come. But 
no one really understands how much it 
all hurts you. You love your brother 
very much, and so you feel his pain in 
your heart." At that, Weinberg wrote, 
"Tears streamed down my cheeks. I 
could not speak." 

This extraordinary story illustrates 
the need to understand context, derived 
from the balanced assessment of a 
patient, an assessment wonderfully for- 
mulated and permissive of the begin 
ning of healing and the beginning of the 
disappearance of Weinberg's pain. 

As powerful as all these narratives are, 
I hear — no, I feel — the expected push- 
back: No time to do this. Nice views from 
another time and place. How many times 
has this message about the primacy of 
the relationship between patient and 
physician been made from the pulpits of 
HMS? How can one reconcile such a fun 
damental message with the reality ol 
clinical medicine as currently experi- 
enced? Where is the Time to Heal that 
Kenneth Ludmerer's extraordinary book 
has challenged us to restore? 

It would be disingenuous to offer a 
simple answer. It is possible however, to 
think of our own arenas of influence 
and to commit to change. And it is pos- 
sible to coalesce those change efforts 
with other kindred spirits for the sake 

of preserving what we feel is at the core 
of effective doctoring, of preserving the 
kind of caring for the patient we would 
seek for those close to us as well as our- 
selves. Technologically correct care that 
is contextually wrong must stop. 

What does this mean for us as prac- 
titioners and as teachers? What can we 
achieve in our domain? Preserve, as 
HMS Professor of Social Psychology 
Elliot Mishler puts it, the Voice of the 
Liteworld as well as the Voice of 
Medicine, which are the essential ele- 
ments for healing. Hear, acknowledge, 
and value this Voice of the Patient. As 
poet and physician William Carlos 
Williams observed in his autobiogra- 
phy: "I lost myself in the very properties 
of their minds: for the moment at least 
I actually became them, whoever they 
should be." 

To preserve the patient's voice we 
need to define, among other things, a 
new form for the medical record. 
Physician William Donnelly suggests 
that, "If patient-centered medicine is to 
become a widespread reality in academ- 
ic medical centers, educational initia- 
tives must include reform of the medical 
record" — a record, he argues, that must 
pay written attention to the person and 
perspective of the patient throughout 
the course of medical care. 

Teach focused communication skills 
in all specialties so that the voice of the 
patient is expressed and heard. Seek the 
voice of the team and allow its expres- 
sion. Speak with the nurses. Find the 
student or house officer caring for your 
patient and make it a point to bring him 
or her to the bedside, especially if an 
emotionally laden message needs dis- 
cussion. Recalibrate the context of care 
being delivered and insist that the per- 
spective of illness be honored. Medical 
ethicist Kathryn Hunter reminds us 
that, "The practice of medicine is an 
interpretive activity." Let's make it so. 

The continued dissolution of the 
patient/physician relationship erodes 

our ability to care for the sick. Speak to 
the issue of: No time to do this today! 
Usurp the objections and speak to 
them. We should take George Bernard 
Shaw's challenge to heart: "The reason- 
able man adapts himself to the world. 
The unreasonable man persists in trying 
to adapt the world to himself. 
Therefore, all progress depends on the 
unreasonable man." 

We can operate within our own 
spheres of influence and, on a good day, 
pick a bigger windmill to tilt against. 
The declaration of William James, Class 
of 1869, fits well: "I will act as if what I 
do makes a difference." 

Let us renew ourselves by reaffirming 
the fundamental joy that brought us to 
medicine in the first place. Help the 
medical young to see within our respon- 
sibilities an unparalleled opportunity 
for personal and professional growth, as 
well as the chance, as Rita Charon 
writes, to "glimpse the nobility, the 
strength, [and] the tenacity of our fellow 
human beings." We cannot let the core 
elements of doctoring lapse; too much is 
at stake. Rather, let's commit in our 
work to sustain the passion of caring 
rooted in the message offered by Mother 
Teresa: "We can do no great things, only 
small things with great love." ■ 

Charles J. Harem '66, the Harold Amos 
Academy Professor of Medicine at HMS, is 
also director of medical education at Mount 
Auburn Hospital and director of faculty 
programs in medical education at the Shapiro 
Institute for Education and Research at Beth 
Israel Deaconess Medical Center 

Permission for select quotations in this article 
was granted courtesy of Abraham Vcrghesefor 
"The Physician as Storyteller" (Ann Intern 
Med 2001;B5:1012-17); Georges Brochardt, 
Inc., for Chekhov, by Henri Troxat (copyright 
1986); Faith Fitzgerald for "Curiosity" (Ann 
Intern Med 1999:130:70 72); and Richard 
Weinberg for "The Laying On of Hands" (Ann 
Intern Med 1992;117:83-84). 




On the heels of selective reportinq of data by pharmaceutical 
companies, a medical editor calls far transparency in clinical trials. 

D R A 7 E N 


r3.tiCIltS CnXOll in clinical trials as altruistic volunteers 
hoping to contribute to the understanding or treatment 
of disease. In the past few years we have seen some trial 
sponsors, especially commercial sponsors, selectively 
releasing information from these trials to cast their 
products in an undeservedly favorable light. Without a 
check on this impulse, medicine risks losing the trust 
of the volunteers who are essential to clinical research. 
The best way to retain their trust is to have all clinical 
trials registered upon inception, in a public database. 

Because all medicine is taught by exam- 
ple, let's examine the story of a class of 
compounds meant to selectively inhibit 
the metabolism of arachidonic acid. 
This essential fatty acid is found esteri- 
fied to membrane phospholipids con- 
tained in many foods, such as the butter 
you spread on your toast this morning. 
In an appropriately activated cell, 
enzymes act on these phospholipids to 
liberate arachidonic acid into the cellu- 
lar microenvironment. 

Several decades ago we learned that 
the arachidonic acid so released was 
transformed into thromboxanes and 
prostaglandins. We also learned that 
aspirin and nonsteroidal anti-inflamma 


tory drugs, or NSAIDs, inhibited what 
was then thought to be a single enzyme, 
termed cyclooxygenase (or COX), that 
was responsible for the first step in that 
transformation. These insights helped 
explain why aspirin and NSAIDs are 
powerful medicines: they inhibit the pro- 
duction of the end products of arachi- 
donic acid cyclooxygenation that cause 
inflammation and pain. These insights 
also explained why these drugs have 
many side effects; they also inhibit for 
mation of the beneficial products of 
arachidonic acid metabolism. 

By the late 1980s, we had learned that 
the COX story was more complex than 
we had originally thought. The key obser- 

vation was that there was more than one 
form of COX. The first form, COX-1, was 
thought to be the housekeeping form, 
responsible for the everyday activities of 
the body's chemistry, helping, for exam- 
ple, to maintain a mucus layer on some 
surfaces and enhancing microcirculation 
in some tissues. The second form of the 
enzyme, COX-2, was believed to be the 
source of inflammation in arthritis; it 
was the "bad guy." 

It seemed reasonable that if we could 
selectively inhibit this second form of 
COX, we could stop the bad guy while 
preserving the housekeeping functions 
of COX-1. This meant that it would be 
theoretically possible to develop an 
arthritis pain reliever that didn't cause 
gastrointestinal side effects. By the early 
1990s the drug companies had taken up 
the challenge and had developed selec- 
tive inhibitors of COX-2. These drugs 
were originally approved on the basis of 
their ability to control arthritis pain, but 
the real prize was to show a better gas- 
trointestinal safety profile than standard 
NSAIDs. Two companies launched a 
series of clinical trials hoping to prove 
that their drugs lessened arthritic pain 
without causing gastrointestinal side 
effects. After the trials were completed in 
2000, the companies raced to get the 



By 2004, the pharmaceutical industry 
worth of COX-2 inhibitors per year. In a single day, the 

sales of these compounds 


information to the Food and Drug 
Administration (FDA), in hopes that 
the FDA would allow them to claim 
enhanced gastrointestinal safety. 

The first trial, known as the CLASS 
(Celecoxib Long Term Arthritis Safety 
Study) trial, was published in the Journal 
of the American Medical Association (JAMA). 
In this paper the authors hoped to show 
that Pfizer's drug celecoxib, or Celebrex, 
could inhibit arthritis pain without gen- 
erating gastrointestinal side effects. The 
primary outcome specified in the trial 
was ulcer complications. In the trial data, 
the reported difference in the frequency 
of these complications between celecoxib 
and the older agents could have occurred 
by chance nine times out of a hundred. 
When the trial sponsors submitted a 
report on the study to JAMA, though, they 
expanded the data set to include both 
symptomatic ulcers and ulcer complica- 
tions, thereby shifting the statistical odds 
to two out of a hundred, a ratio more 
favorable to their claims. 

Patients were enrolled in the trial for a 
year, but the researchers submitting the 
trial told JAMA's editors about only the 
first six months of results, which is what 
JAMA published. A later examination of 
data from the full year revealed that even 
the small benefit of reduced sympto- 
matic ulcers and ulcer complications had 
evaporated by the end of 12 months. 
After FDA officials reviewed the celecox- 
ib data, they refused to allow the manu- 
facturer to advertise the drug's absence 
of gastrointestinal side effects, because 
the proportion of subjects experiencing 
these side effects from celecoxib did not 
differ all that much from the proportion 
who suffered such side effects while 
receiving standard treatment. 

In the meantime, the researchers were 
also tracking cardiac events, and at six 
months they found no difference between 
the two study groups. That point is rele- 
vant to another trial, one that the New 
England Journal of Medicine (NFJM) pub- 
lished a few months later, in November 

2000. The design for the VIGOR (Vioxx 
Gastrointestinal Outcomes Research) 
trial of Merck's drug rofecoxib, or Vioxx, 
resembled that of the CLASS study. Yet 
the VIGOR trial had two critical differ 
ences: control patients took only naprox 
en instead of either of two different 
drugs, and Merck barred anyone on low- 
dose aspirin from the trial, thereby 
decreasing the possibility of gastroin- 
testinal side effects in the rofecoxib group 
but enhancing the possibility of seeing 
cardiovascular side effects. 

In this trial, the good news was that 
rofecoxib produced fewer gastrointesti 
nal side effects than naproxen. But 
researchers also made an unexpected 
observation: three to four times as many 
heart attacks occurred in the active - 
treatment group as in the comparison 
group. The rates were low — there were 
few events in either group — but the pro- 
portion was higher. This information 
raised some concern about the possibili 
ty of cardiovascular complications with 
rofecoxib, but since the signal was unex- 
pected, the data were gathered in a fash 
ion that did not allow firm conclusions 
about cardiovascular risk to be drawn. 

In August 2001, about nine months 
after the VIGOR trial was published, 
JAMA published a meta-analysis look- 
ing at the CLASS trial, the VIGOR trial, 
and a large placebo group from a third 
trial. The investigators used data from 
CLASS and VIGOR, made publicly 
available on an FDA website, that 
included additional events that were not 
reported in the original journal articles. 
This meta-analysis found an increased 
frequency of cardiovascular events in the 
two groups taking COX 2 inhibitors. 
Their analysis came to the same conclu 
sion: the drugs could cause heart prob 
lems, but the exact nature of the risks 
was not known with certainty 

The FDA then asked Merck to con 
duct a trial to demonstrate the cardio 
vascular safety of rofecoxib, but allowed 
Merck to continue to sell the drug. More 

than four years would pass before the 
data from that trial became available. In 
the meantime, both Pfizer and Merck 
launched massive campaigns to market 
their drugs as safe and effective. 

To produce the initial data on celecox 
ib and rofecoxib for the CLASS and 
VIGOR trials, approximately 13.000 peo- 
ple had volunteered to be study partici 
pants, presumably because they believed 
their information would be used impar- 
tially in clinical decision- making. Yet the 
trials' sponsors selectively filtered what 
they told the public. In the CLASS trial, 
they showed only the positive data from 
the first six months. In the VIGOR trial, 
cardiovascular events that occurred after 
the prespecified cutoff interval for 
adverse events were reported to the FDA 
but were not part of the article submit 
ted to NEJM. 

How rapidly should Merck have react- 
ed to this cardiovascular signal? Although 
missteps are always clearer in hindsight, 
it is still fair to ask: What force was guid 
ing clinical trial design and implementa 
tion? Merck made the decision to market 
its drug vigorously while awaiting the 
results of a trial the company knew 
would take four years to complete. In half 
that time Merck could have designed and 
completed a trial in patients with arthri 
tis who were also at high risk for cardio 
vascular disease. The company would 
have had its answer in 2002 rather than 
2004. Was this delay fair to the patients 
who had volunteered to participate in the 
VIGOR trial — or to the millions of peo 
pie purchasing Merck's product? 

Consider the following analogy. If I 
smelled smoke in my kitchen as I was 
leaving for work in the morning, I would 
not ask my neighbor to watch for a fire, I 
would look for the source of the smoke. 
The behavior of Pfizer and Merck resem 
bled that of a homeowner who smelled 
smoke and said, "Well, I don't see a fire. I 
think I'll go to work." Rather than inves- 
tigate the potential problem further, they 
marketed their drugs relentlessly. 



selling $5 BILLION 
unt ofmonev that collective 

was senir 
: amount o 



They were so successful that by 2004, 
when Merck withdrew its drug from the 
market, the pharmaceutical industry was 
selling S5 billion worth of COX 2 
inhibitors per year. To put that number 
in perspective, consider that, in a single 
day, the amount of money that collective 
sales of these compounds generated 
would have paid the tuition of all the 
students now enrolled at Harvard 
Medical School. The drug manufacturers 
were making enormous amounts of 
money, thanks largely to advertising 
that tended to focus on the potential 
for decreased gastrointestinal side 
effects and did not mention the possi- 
ble cardiovascular risks. 

The companies also began to pursue a 
secondary agenda: both drugs were 
involved in trials to prevent colon cancer. 
Pfizer gave its drug to the National 
Cancer Institute (NCI), which in turn 
sponsored the A PC (Adenoma Prevention 
with Celecoxib) trial Merck under- 
took its own trial, called APPROYe 
(Adenomatous Polyp Prevention on 
Vioxx), which sought to determine 
whether rofecoxib would decrease the 
number of future polyps in patients 
who had already had one colonic polyp. 
Both companies were trying to create 
new markets for their drugs. 

But in September 2004, when an early 
data analysis from APPROYe suggested a 
cardiovascular problem, Merck pulled 
rofecoxib from the market. At this point 
the company met its responsibility to the 
trial participants. These volunteers had 
taken a risk to participate in the trials, 
and now Merck was making public the 
information gathered from them. I think 
the company should he acknowledged 
for taking that action. 

The NCI investigators then looked 
more closely at their celecoxib trial, 
because they had not been doing exten- 
sive cardiovascular monitoring. They 
convened an external panel of reviewers, 
who reexamined all the data in the 
Pfizer- NCI colon polyp trial and found 

an increased incidence of cardiovascular 
events. The NCI halted the trial. 

In September 2004, following Merck's 
withdrawal ot Vioxx, I asked, as editor 
in chief of NEJM, the authors of the APC 
and APPROYe trials to send us their car- 
diovascular safety 7 data, because health 
care professionals needed to know the 
whole story. This was information one 
could not get by reading the New York Times 
or browsing the companies' websites 

We worked hard to get these data sets 
on the cardiovascular side effects 
observed in the APC and APPROYe tri 
als. We had a deadline, in that the FDA 
had already scheduled an advisory com 
mittee meeting on these drugs. We 
wanted to have the papers out to both 
the public and the committee members 
before they met in February 2005. 

The data in these papers were unnerv- 
ing. In the APC trial, the one the NCI 
sponsored and later stopped because of 
enhanced cardiovascular risk, two to 
three times more cardiovascular events 
occurred in the active-treatment groups 
than in the placebo groups. The APPROYe 
trial showed a twofold increase in car 
diovascular events related to thrombo 
sis, which substantiated the results 
reported in the VIGOR paper and 
placed the risk analysis on much firmer 
scientific grounds. 

We distributed our papers to the FDA 
advisory committee members the day 
before their meeting. At the meeting the 
Pfizer representatives made a presenta- 
tion that failed to mention the APC trial, 
despite our earlier data distribution. 
When asked about their omission, the 
Pfizer representatives claimed they 
could not present the NCI data because 
they did not own the data. 

Was this fair to the people who partic- 
ipated in the trial? How can Merck or 
Pfizer or any drug company hope to con- 
vince people to enroll in clinical trials if 
the potential participants suspect that 
the companies will make public only the 
favorable data? Patients put themselves 

at risk in clinical trials mostly because 
they are altruistic; after all, standard care 
is always a choice. They are hoping, per- 
haps, to achieve a better outcome for 
themselves, but in many trials, they are 
not even ollcred that possibility. The 
only way we can convince patients to 
continue to make such a sacrifice is by 
assuring them that il they participate, 
their data will contribute to a decision 
making process that is untainted by 
profit motives. 

For altruistic patients to continue to 
participate in clinical trials, they must 
know that the rules of the game are pub 
lie. They must know that their data are 
part of the public record. As the editor of 
a major medical journal, I have decided 
that starting this fall we w'ill not publish 
papers from clinical trials that are not 
registered in a public database. Had the 
VIGOR trial been registered in a trial 
registry at inception, for instance, the 
editors of NEJM would have known that 
the cutoff date for adverse events was set 
to be a month before the cutoff date for 
the gastrointestinal outcome. 

I urge physicians who help enroll 
patients in clinical trials to refuse to par 
ticipate in trials that are not registered. 
Together we can ensure that the altruism 
of clinical trial participants is fully recog 
nized and rewarded. ■ 

Jeffrey M. Drazcn 72, the editor-in-chief of the 
New England Journal of Medicine, is also 
the Parker B. Francis Distinguished Professor 
of Medicine at HMS. He maintains affiliations 
with the Department of Medicine, the Division 
of Pulmonary and Critical Care, and the 
Partners Asthma Center at Brigham and 
Women's Hospital. 







A physician-journalist explores the impact of the 
evolution of media on the public's access to medical information 

1 iirCC WCCKS beiOrC my graduation from medical school in 
the spring of 1969, 1 wandered down to the student lounge to catch 
the evening news. The broadcast I watched, the "Huntley-Brinkley 
Report," happened to carry a story from Chicago in which the American 
Medical Association (AMA) had, earlier in the day, held a press confer- 
ence to announce its opposition to the proposed appointment of a 
Boston physician, John Knowles, to become undersecretary of health. 
The association objected to Knowles because he was too liberal in his 
views on health care. He was advocating something called "universal 
health care," which at the time were terribly dirty words in Chicago. 


A tremendous amount of information has been developed 

some not, to SATISFY THE 
number of news outlets now have for information. 

Now had the AMA held auditions to find 
the worst possible spokesperson for 
their cause, they could not have done 
better than the ancient trustee they 
thrust before the cameras to read a pre- 
pared statement. After he finished, the 
press began asking him questions, and he 
became so flustered that his handlers 
had to lead him off the stage. And when 
they cut back to Huntley and Brinkley, 
the two newscasters were laughing so 
hard at this inept performance that they 
had to take a commercial break to regain 
their composure. 

The very next morning I found in my 
school mailbox a form letter inviting me 
to join the AMA as an about-to-be new 
doctor. In the most impulsive moment 
of my life, I grabbed a pen and wrote on 
the letter something like, "If what I saw 
on the news last night is any indication 
of your policy, I do not care to join. 
Thank you." And I dropped the letter in 
the mailbox, never expecting to hear 
another word. 

To my utter astonishment, about 
three weeks later, I received a long per- 
sonal response from the executive 
director of the AMA detailing his oppo- 
sition to Knowles. By now I was 
intrigued with the subject so, again on 
impulse, I sent the letter off to Knowles 
with a cover note saying, "Here's what 
I'm hearing. I thought you might be 
interested." He wrote back and we 
became pen pals. 

At one point in our correspondence 
Knowles wrote, "If you ever come to 
Boston, look me up, and we'll get to 
know each other," which is what we did. 
At that time he happened to be part of 
a large group of people, mostly from 
Harvard, who were taking over the 
operation of the ABC station in Boston 
in the spring of 1972. One day he asked 
me to consider hosting a half-hour 
morning program for the public, which I 
did each day before going to work at the 
hospital. That's how my career in televi- 
sion journalism began. 

Worlds Collide 

In the 1940s and 1950s, the worlds of 
medicine and media had almost nothing 
to do with each other. The world of 
medicine gazed at the world of media 
with a kind of lofty arrogance, and the 
world of media regarded the world of 
medicine with a distant respect and 
even awe. But in the 1960s, some enter- 
tainment programs started to portray 
the world of medicine through the lives 
of physicians. "Marcus Welby, MD" was 
a top-rated television program from 
1969 to 1976. The kindly doctor solved 
every medical problem in 28 minutes, 
never got ruffled, and never handed a 
bill to the patient. Who wouldn't want 
a doctor like that? 

More important, at about the same 
time, the news divisions of local stations 
and networks began to realize that the 
public had an appetite for health and 
medical information. Surveys in the 
early 1970s consistently ranked medi- 
cine and health either first or second on 
the list of topics of interest. 

Just at the time I was entering this 
world, the news divisions of all the net- 
works and the local stations were start- 
ing to cover medicine. Of course, we 
know what happened from that point 
on: these two worlds, which had previ 
ously paid so little attention to each 
other, began engaging in a dance with 
great interest and even vigor. 

That interaction served the public on 
many levels. I can't prove that what we 
do in the media benefits the public in 
terms of the ultimate goal, which is to 
change health behavior. But I would like 
to think that we play a significant role 
in trying to present information that is 
accurate, helpful, and understandable. 

Information Overload 

Since I entered the world of journalism 
full time more than 20 years ago, we 
have witnessed revolutions in the 

worlds of medicine and media. The 
world of media has seen an extraordi 
nary fragmentation in the sources of 
information to be conveyed to the pub 
lie. When I joined ABC News full time 
in 1984, the three existing networks — 
ABC, CBS, and NBC— claimed 90 per- 
cent of the viewing audience at 6:30 in 
the evening for the news programs. 

Nowadays in that time slot, those 
three networks — along with CNN and 
Fox — capture approximately 40 per- 
cent of everyone watching television. 
The rest are, of course, watching cable, 
and many people are not watching at all; 
they're getting their information from 
the Internet. 

This fragmentation of the world of 
media in just the past two decades has 
produced a splintering effect that has led 
to some dangerous phenomena. The 
frantic competition among news organi- 
zations has put the pressure on to be first 
and, we hope, right, but certainly to be 
first. I shudder at what I see happening 
around me. I can control what I do, but 
I can't control much else, even at ABC, 
although I certainly have a voice there. 

In addition, a tremendous amount 
of information has been developed from 
all kinds of sources, some valid, some 
not, to satisfy the voracious appetite 
that the large number of news outlets 
now have for information, especially 
about health. As a journalist, I find it 
annoying. As a physician, I find it fright 
ening. And as a consumer, I find it wor- 
risome to see the enormous amount of 
information that is streaming to us from 
all sources. 

Unpatrolled Borders 

Twenty years ago, the flow of medical 
information was well controlled by 
the so-called establishment. Medical 
researchers would carefully present 
their findings to the journals. The jour- 
nals would process this information 
thoughtfully and, when they believed 



rom all kinds of sources, some valid, 
VORACIOUS APPETITE that the large 
especially about health. 

it was ready for physician consump- 
tion, they would publish it. Members 
of the media would all observe the 
embargo dates and rules. And the pub- 
lic would not receive the information 
until it had been carefully massaged 
through that process. 

We face a difficult time in which the 
gatekeepers and the processes that 
served us so well for so long have bro- 
ken down. Now underlying both sides 
of the medicine/media equation are 
philosophical questions that have always 
intrigued me: Who owns medical intor 

Today, of course, information flows 
to the public from all kinds of sources, 
with little care devoted to its process- 
ing. And so journalists and physicians 
alike face a critical challenge in trying 
to keep the information orderly, honest, 
and useful. 

All of this, of course, has led to an 
enormous increase in the potential for 
conflicts of interest on both sides of the 
medicine media equation. On the side 
of the media, frightening cases have 
arisen of journalists hoping to promote 
their own careers, scheming to obtain 
new s in illegitimate ways, and trying to 
present information before it's been 
thoughtfully processed. 

mation? Who has the ultimate right to 
decide when it should be presented to 
the public — presumably the ultimate 
beneficiaries of medical information, 
both good and bad? 

For years, the medical establishment 
or the government that financed so 
much of the research was thought to 
own that information, and the data 
were processed carefully. But many 
would argue that careful processing 
also had a downside in that it kept 
timely information from the public. 
These critics would argue that medical 
data should belong to the public and its 
representatives. And those representa- 
tives — for better or for worse — are the 

press and the public square. We will 
see a continuing tension between those 
who are trying to retain ownership of 
medical information within the estab 
lishment — and the ability to control its 
release to the public — and those who 
are demanding that medical informa 
tion be available instantlv. 

Perilous Surf 

The big catch phrase in the world of the 
media today is VoD, or Video on 
Demand. Everyone is scrambling to fig 
ure out how to build databanks of infor 
mation that individual consumers can 
access immediately through whatever 
electronic means available when they 
decide they want to know something. 

Many members o( the media are pre- 
dicting that, within the next decade, 
television will no longer carry sched- 
uled programming. We will not be able 
to tunc in at a certain time even to see 
the evening news. Any time we want 
any kind of information, whether it's 
the news in general or medical reports 
in particular, we will simply flick on 
our computers or BlackBerries or what- 
ever devices we will have by then. We 
will punch in the subject and receive an 
immediate download of multiple sources 
reporting on that particular topic. And 
that's how we will stay updated through 
out the day. 

If you think we have problems com 
trolling the flow of information now, 
consider what it will be like in that 
brave new world when it's instant, 
downloadable news all day long, seven 
days a week. That will be the future of 
information dissemination about health 
and medicine — something for us all 

to ponder. 

Timothy Johnson, MD, is the medical editor at 
ABC News, the founding editor oj the Harvard 
Medical School Health Letter, and co-edi- 
tor of the Harvard Medical School Health 
Letter Book. 




The dean of HMS explains how a world newly flattened by technology 

_d dv^ll W 111 LC 1^ my colleagues in the dearfs office join the chairs 
of Harvard Medical School's clinical and basic science departments for a 
weekend retreat on Cape Cod. As I prepared for this year's meeting, I reflected 
on the changes that have occurred, over the course of the eight years of my 
tenure as dean, in the relationships binding the entities that compose the broad 




s giving rise to fresh dimensions in medicine. 


community we call Harvard Medicine. Complexity is a way of life at HMS, 
and it drives the way we connect with one another. At the retreat, I consid- 
ered the non-traditional and, indeed, sometimes enigmatic nature of our rela- 
tionships, particularly as they speak to the governance and strategic planning 
issues across our community. 


major impact on the many 
collaborations that have emerged, both locally and 

My recent reading ol The World h Flat: A 
Brief History of the Twenty first Century, by 
New York Times foreign affairs columnist 
Thomas Friedman, reinforced my notion 
of the complicated interrelationships 
underpinning the HMS community. 
Friedman analyzes brilliantly the com- 
plexity of international relations, partic- 
ularly in the business and educational 
venues that have emerged in the wake of 
the technological revolution, the Internet, 
and 24/7 financial transactions. 

This "flattening" of our world has had 
a profound impact on the way we con- 
duct our international business affairs. 
Outsourcing, insourcing, the juggling 
of trade deficits, and offshore economic 
arrangements have each resulted in new 
constructs in the relationships between 
business, government, and educational 
entities throughout the world. 

Friedman uses the example of Dell, 
now the world's largest computer com- 
pany, to illustrate this principle. Dell 
sells between 140,000 and 150,000 com- 
puters each day, and the success of the 
company depends on worldwide trans- 
actions and delivery routes. But there is 
more to it than that. Research teams in 
Texas and Taiwan collaborate on the 
design of new products and the modifi 
cations of existing products. Ten coun- 
tries — particularly China, Malaysia, 
Korea, Japan, and Taiwan — produce the 
individual components. Production quo 
tas, quality control, and shipments for 
computers all occur with just-in-time 
delivery in a 24/7/365 world. 

In another example, Friedman describes 
the origins of Jet Blue, the economy air 
line headquartered in Salt Lake City. 
There, nationwide flight reservations are 
managed by a group of Mormon mothers 
working from home. Friedman compares 
this example of the good use of inter 
connectedness to Osama bin Laden's 
exploitation of similar mechanisms to 
create a network of terrorists intent on 
destroying the ordinary machinery of the 
Western world. 

In both instances, the structures ol 
success and of destruction have depend 
ed on harnessing the power of the 
Internet to coordinate activities that 
have led to a remaking of our world. 

These examples provide an opportu 
nity for considering the ways that HMS 
and its companion institutions relate to 
one another. These interactions now 
include new collaborations with other 
faculties at Harvard University — espe- 
cially the Harvard School of Public 
Health — and with MIT. The networking 
with our hospitals forms a structure that 
has been flattened in a comparable 
way — on the whole for the better. How 
has this come about? 

Virtuous Realities 

When I arrived as dean in 1997, 1 realized 
that a major initiative in information 
technology would be essential to ensure 
connectivity within the broad Harvard 
medical community. We established a 
new system for community interchange 
through our eCommons intranet, carried 
out a $28 million renovation of the 
Countway Library of Medicine to make 
it fully digital and wireless, and estab 
lished new T messaging systems, which 
permit me to send instant emails to more 
than 14,000 people at a time. 

The impact of all of this technology on 
the community is that emails have large 
ly replaced telephone calls, resulting in 
enormous efficiencies. The paper trail in 
my office has virtually dried up. Our 
entire medical school curriculum is now- 
online, accessible to our students in 
Chile, Tanzania, Peru, and Russia. 

The success of the digital renovation 
of the library has been accompanied by a 
remarkable 50 percent reduction in the 
onsite usage by our students and faculty. 
Many of the features of the digital library 
are now accessible to any member of our 
academic community — students, faculty, 
and staff — from their computers any- 
where in the world. A single login name 

and password can provide access to 
more than 800 journals online, and we 
use Google to search for information 
that in the past would have taken days or 
weeks to find. 

Taught in the Web 

Working with Griffin Weber, a recent 
MD-PhD graduate, John Halamka, 
HMS associate dean for educational 
technology, has developed an important 
asset called MyCourses. This Web por- 
tal allows the assembling of material for 
lectures and the transfer of information 
to what, in the recent past, would have 
been the syllabus. 

The MyCourses database contains 
more than 250,000 items. Our faculty 
can easily access material on fields rang 
ing from histology to pathology, and 
from pharmacology to physiology, as 
well as on clinical cases. They can use 
the latest information to modify their 
lectures and tutorials. MyCourses also 
allows them to incorporate animation 
as a learning tool. 

In addition, we can now provide time- 
ly assessments of our students' perform- 
ances with rapid grading and appropri- 
ate commentary that provides confiden- 
tial information to the dean's office. The 
students, in turn, can offer instant evalu- 
ations of lectures and other faculty activ- 
ities, providing important feedback on 
the quality of their education. Already 
students, faculty, and staff access the 
MyCourses website 18,000 times daily — 
and the number keeps growing. 

Collaborative Efforts 

The expansion of our education activi- 
ties has extended to new programs 
within the School and in collaboration 
with other faculties at Harvard and 
MIT. We recently established, for exam- 
ple, an MD-MBA program designed to 
create a meaningful interface between 
medicine and business. This program 


entitles students, after five years of 
study, to earn joint degrees. 

We have also, in our doctoral programs, 
established exciting new opportunities in 
chemical biology and in systems biolo- 
gy — the new physiology — to allow stu- 
dents to enter from a common, single 
portal in appl)ing to Harvard University. 
Following acceptance, the students can 
then decide which specific track they 
wish to pursue. They can choose among 11 
programs, ranging from biophysics to sys- 
tems biology to chemical biology to neu- 
roscience. We have also established a new 
MD-PhD program in the social sciences. 

We are now celebrating the 35th 
anniversary of the MIT-Harvard Health 
Sciences and Technology program. We 
have just completed a program review, 
which attests to the remarkable success 
of its graduates, more than 80 percent of 
whom have assumed important academ 
ic appointments. 

Dream Teams 

The flattening of the HMS community 
has also had a major impact on the many 
new clinical collaborations that have 
emerged, both locally and internation 
ally. In addition, it has required us to 
develop new mechanisms for trans 
system collaboration and research. 

The first of these was the Dana 
Farber/Harvard Cancer Center, now in 
its seventh year. Through this initiative, 
more than 800 investigators from a 
dozen of our institutions have developed 
new research interactions not dreamed 
of ten years ago. One of the outstanding 
results of this collaboration has been the 
awarding of seven Specialized Programs 
of Research Excellence, or SPORE, grants 
to investigators in search of an under 
standing of and treatments for cancers 
of the lung, kidney, breast, prostate, 
ovary, skin, and blood. 

We have also established a Harvard 
wide entity to seek understanding of 
neurodegenerative disorders and to col 


-^ , ^ 

. X 

laborate with the recently emerging 
work in stem cells. With a focus on 
Alzheimer's disease, amyotrophic lateral 
sclerosis, Huntington's disease, and 
Parkinson's disease — and with the addi 
tion over the past two years of a new, 
international collaboration on multiple 
sclerosis — this group collaborates 
across eight of our hospital-based 
departments, through the network of 
investigators that compose the Harvard 
Center for Neurodegeneration and 
Repair, or HCNR. 

One of the many exciting initiatives 
within the HCNR is the Laboratory for 
Drug Discovery in Neurodegeneration 
at Brigham and Women's Hospital. 
Headed by Peter Lansbury, the labora 
tory has taken on the challenge of iden 
tifying small molecules from the chemi 
cal biology laboratories to try to turn 
off some of the abnormal protein folding 
that is now known to be associated 
with neurodegenerative conditions. 

Also contributing to the School's 
innovative efforts is the Broad Institute, a 



All this connectivity has not 


has also resulted in SEMINAL CHANGES! 

collaboration between Harvard and MIT 
that is composed of interdisciplinary 
researchers dedicated to developing 
tools for genomic medicine. These 
experts focus on the molecular basis of 
cancer; metabolic disorders, including 
diabetes, obesity, and heart disease; and 
inflammatory and infectious diseases. 

The Harvard Stem Cell Institute also 
is providing innovation. Seven Harvard 
schools, seven teaching hospitals, and 
nearly a hundred scientists are banding 
together in this ambitious new institute, 
whose mission is simple: to use stem 
cells to help the 150 million people 
nationally living with or dying from five 
types of organ and tissue failure. 

Remaking the Dean's List 

All this connectivity has not only made 
our community the most successful of 
its kind in the world in education, 
research, and patient care, but it has 
also resulted in seminal changes in our 
day-today functions. 

As the dean of the School, my first 
responsibilities are to the ten basic sci- 
ence departments on the Quad. These 
range from the basic science Departments 
of Genetics, Biological Chemistry, Cell 
Biology, Pathology, Neurobiology, Micro 
biology, and Systems Biology, to more 
clinically relevant efforts in Ambulatory 
Care and Prevention, Health Policy, and 
Social Medicine. 

One of the challenges we face is that, 
increasingly, the faculty members in 
these departments hold doctorates 
rather than medical degrees. They pos 
sess extraordinary talent but often 
maintain a rather narrow focus. Inviting 
them to participate in the educational 
mission and assuring their contributions 
here has created challenges in the MD 
curriculum, although many of them 
clearly are actively engaged in teaching in 
the equally large PhD program. 

Each of our 45 clinical departments 
has a jointly appointed chair who reports 


t>nly made our community the 

: world in education, research, and patient care, but it 


both to the dean and to a hospital head. 
One substantial effort we have undertak 
en in the past five years has been the 
establishment of a routine review of all 
our departments as a shared effort 
between the dean's office and the hospi- 
tal leaders. We have reviewed 30 of the 
55 departments over the past four years 
and have established a rotation that 
allows us to complete all of the reviews 
within a five- to seven-year period. 

In my role as dean in this flattened 
community, I chair the Governance 
Committee of the Dana-Farber/Harvard 
Cancer Center, serve as president and 
chief executive officer ot the Harvard 
Center for Neurodegeneration and 
Repair, and serve as chair of the board 
of Harvard Medical International, which 
works in nearly 30 countries worldwide. 
My responsibilities as dean only contin 
ue to evolve. I am president of the 
Massachusetts Biomedical Research 
Corporation, for example, which was the 
vehicle driving the state bond funding for 
the large expansion of the Charlestown 
campus of Massachusetts General 
Hospital. I also serve on the operating 
committee of the Broad Institute and, as 
a side matter, try to keep key stem cell 
researchers from moving to California. 

Centers of Gravity 

When we consider the governance of this 
flattened community, it becomes clear 
that conventional models of organization 
are no longer useful in determining our 
future directions. HMS is not a hub-and- 
spoke model. We have multiple hubs and 
multiple spokes. Nor is HMS a hierarchi- 
cal model — no one individual is in charge. 
Instead — and here I'm reverting to my 
inclinations as a neuroscientist — the 
HMS model is really a network, as in a 
neural network with multiple nodes of 
connectivity, each with its own center of 
gravity and focus yet interconnected in 
multiple and complicated ways with the 
other nodes. To an important degree, 

much of the activity generated is self 
organized, not managed. 

As we look forward to our continued 
work within this flattened community, 
how do we ensure that we are taking full 
advantage of our many opportunities and 
that we are adequately tackling our many 
challenges? One area of concern is the 
way we continue to close ranks without 
full cooperation around the issues of 
intellectual property, patents, and licens- 
ing. At a time when Boston is emerging as 
the country's most attractive venue for 
biotech and pharmaceutical companies 
and when the science of medicine is mov- 
ing rapidly toward new opportunities in 
translational research, our current system 
is too disconnected and inefficient to do 
full justice to the broader relationships 
possible between academia and industry. 

It a venture capitalist or a biotech 
company leader wishes to elicit the ideas 
of our faculty members, too often we are 
inaccessible and disconnected. Moreover, 
our ability to deliver on promises of such 
relationships has not improved greatly 
over the past decade. 

We also face a major challenge with 
respect to the expansion of Harvard 
University's academic community to the 
Allston campus. Despite three years of 
planning and the reporting of a science 
and technology committee about areas of 
focus and priority for that campus, we 
have yet to witness a sustained academic 
appreciation for and commitment to the 
opportunities there. As Harvard President 
Larry Summers has made clear, life sci- 
ences will form the principal focus of 
activities at that site, and unified graduate 
programs will evolve. 

The goal, in part, for the Allston initia- 
tive is the development of new activities 
that connect the basic sciences of mathe- 
matics, physics, chemistry, and computer 
science with biology, but the details are 
still a long way from reality. In addition, 
the current plan to move part of the 
Harvard School of Public Health to the 
Allston campus may interrupt many 

joint programs in such fields as epidemi- 
ology, biostatistics, and cancer biology. 

Mission Control 

As we approach the final planning stages 
for the School's new curriculum, we face 
another formidable challenge: how to 
identify best practices in education and 
share with our hospitals and clinical 
departments the responsibilities of pay 
ing for teaching and promoting faculty 
who do it well. 

During the past 35 years our academic 
health centers have evolved through 
steady — even undisciplined — growth. 
The reality is that expanding this clinical 
enterprise has been critical to our ability 
to compete in the health care environ 
ment. Our faculty has grown eight- to 
tenfold since 1970. Our research enter- 
prise also has followed a growth trajecto- 
ry, with support from the burgeoning 
National Institutes of Health, the budget 
of which doubled between 1997 and 2003. 

These marks of success have occurred 
with little increase in the number of our 
students. The annual number of stu- 
dents graduating with medical degrees 
has not changed in more than 25 years, 
and although our PhD programs have 
expanded considerably (graduates of the 
medical school and hospital laboratories 
make up fully 80 percent of Harvard 
University's total in biological sciences 
each year), the attention to educational 
issues has often been trumped by the 
focus on patient care and research. 

At Harvard Medical School, our flat- 
tened world poses challenges that will 
continue to present major opportunities 
to fulfill our mission: to create and nur- 
ture a community of the best people 
committed to leadership in alleviating 
human suffering caused by disease. ■ 

Joseph B. Martin, MD, PhD, is the dean of 
Harvard Medical School as well as the Caroline 
Shields Walker Professor of Neurobiology and 
Clinical Neuroscicnce. 


ion Report 

eunion Report 

Reunion Reports 





■/ "^S 






. -■* 




Reunion Reports 


Reunion Reports 

60th— 1945 Edward Friedman 

The Class of 1945's sixtieth reunion was 
blessed from the start with a beautiful 
day. Our final official reunion was 
attended by 40 of the 75 living members 
of the class. The high point of our week- 
end was Alumni Day when we had a 
class table for lunch and saw old 
friends. It was great talking with Sid 
Jackson, Tom Boles, and Tom Morgan 
well into the afternoon. Then, in the 
evening, at a sumptuous banquet in the 
Faculty Room of Gordon Hall where 
the steaks were thick and juicy, we had 
a wonderful chance to discuss politics 
with Joe Miller, our class member in the 
New Hampshire legislature. 

Coffee accompanied a short business 
meeting and a moment of silence in 
memory of our departed classmates 
whose presence we sorely missed; the 
Class of 1945 has always been a close- 
knit group. Jack Parker announced that 
the class treasury would be able to fund 
a scholarship in our name. At the same 
time a suggestion to meet again as a 
class in two to three years was lobbed 
and met with approval. We will keep 
each other informed of this and other 
class affairs through a periodic newslet- 
ter, which I volunteered to coordinate. 

On Saturday, although the partici- 
pants were reduced in number, the 
class met for lunch at the Harvard 
Club to exchange final thoughts. 
Afterward, many went off to the 
Museum of Fine Arts or to other 
Boston attractions. It was a most sat- 
isfying reunion and left us looking for- 
ward to future get-togethers. ■ 

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55th— 1950 Renee L. Gelman 

The Class of 1950 held its 55th reunion 
in an atmosphere warmed by reen- 
countering old friends. The Alumni 
Day ceremonies and, most importantly, 
the class picture, set the tone for the 
festivities. Although we missed our 
absent classmates, 40 people attended 
the dinner at the Downtown Harvard 
Club on Friday. The view, the weather, 
the conviviality, and the good wine and 

food encouraged a Quaker like meeting 
at which we shared old memories and 
remembered old friends. 

Lunch at my Brookline house on Sat- 
urday was a repeat of our 50th reunion. 
Shel Levin brought the videos of our 
graduation 55 years ago, which we have 
viewed at every reunion. Despite the 
heat, we all enjoyed ourselves, and we 
departed hoping our 60th will be as 
successful. ■ 



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50th— 1955 Mitchell Rabkin 

Our reunion was almost magical, as if no 
time had intervened since graduation. 

The congeniality began on Wednes- 
day evening at the home of Roman and 
Ruth DeSanctis, with a welcoming buffet 
supper, a tradition they generously fol 
low for each five-year gathering. After 
Thursday's activities on the Quadrangle, 
a gala dinner brought out record numbers 
to enjoy a welcome from Joe Martin, Dan 
Federman '53, and George Thibault '69; 
a moment of silence remembering class- 
mates lost; then an excellent meal and 
exquisite views of the Charles River, 
Boston, and Cambridge from the Muse- 
um of Science Skyline Room. 

Friday's alumni business meeting was 
special — 81 percent of our living class- 
mates contributed a record-setting 
sum, more than half a million dollars. 
The Class of 1955 established a perma- 
nent endowment fund for scholarship 
support; classmate Paul Prusky under 
scored its importance with the com- 
ment that the growing indebtedness of 
new graduates "can erode the very 
moral fiber of medicine." 

A weekend at the Clitt House Resort 
in Ogunquit, Maine, capped the reunion, 
where each reflected on the good fortune 
that brought our class to Harvard Med 
ical School and what that has meant over 
the subsequent half century. ■ 




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45th— 1960 Joe Barr and Jane 

Our reunion was enlivened by the pres 
ence of 40 classmates and more than 25 
spouses and friends. We began on 
Wednesday evening with a reception at 
the Heritage on the Garden hosted by 
Dick Wurtman. 

Thursday night we had a class dinner 
at the MIT Faculty Club, overlooking the 
Charles River. A moment of silence was 
observed for those who have left us since 
our last reunion — Al Larson, Clay Sten- 
berg, John Bull, Jay Powers, Larry Sack, 
Jonathan Wirtschafter, Ben Gittes, and 
Mel Gelch. Classmates brought us up to 
date about their lives, families, and 
career changes, and, of course, they 
offered valuable thoughts and insights. 

Friday morning was Alumni Day, fea- 
turing several excellent talks, including 
one about doctors communicating with 
patients, by Charles Hatem '66; one 
about the lessons learned from the 
COX- 2 controversy, by Jeffrey Drazen 72, 

editor in chief of the New England Journal 
oj Medicine; and one on medicine and the 
media, by Timothy Johnson, medical 
editor at ABC News. 

After lunch we traveled to the Ocean 
Edge Resort in Brewster, Massachusetts, 
on Cape Cod. We had a lovely dinner 
there and greeted several classmates 
who could not attend the first couple of 
days. Sirgay Sanger entertained us with a 
tale of how his dog, Oliver, helped him 
connect with autistic children. One 
irreverent classmate wondered whether 
Oliver had billing numbers. On Saturday 
several of us played golf or tennis, per- 
haps not as skillfully as five years ago, 
but still with enthusiasm! A New Eng- 
land clambake and more after-dinner 
conversation brought the day to a close. 

Brunch on the porch Sunday morning 
concluded our time together. Forty-five 
years have passed swiftly; many of us are 
still active in medicine and enjoying 
what we do. May we all be hale and 
hearty for our 50th reunion! ■ 

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40th— 1965 Bruce Chabner 

Approximately 30 classmates from the 
Class of 1965 returned to Boston on the 
weekend of June 10 for the formal med 
ical school program as well as private 

Attendees from Utah (William Barry), 
Florida (Kenneth Ratzan), Minnesota 
(Cecil Chally and Richard Aadalen), 
Michigan (Gilbert Omenn), Indiana (Her 
bert Adams), and other parts of the coun 
try, including many horn the Northeast, 
gathered for dinner on Friday evening, 
June 10, at my home in Newton. 

We reconvened for a clambake on Sat 
urday at John McNamara's home in 
Brockton. What a great pleasure to sec 
our good friends after many years. We 

recognized voices instantly and faces 
within a few seconds, and we usually 
remembered names after a minute or 
two. We shared a lot about our lives, 
families, celebrations, and tragedies, and 
a bit about work, which seems to recede 
in importance as the years march along. 
Many are now retired, or retiring, and 
the rest of us working folks are curious 
about the adjustment. We lingered late 
into the evening, and afterward realized 
what a great bunch of people we were 
privileged to know at HMS. 

Many thanks to those of the Boston 
crowd, including John McNamara and 
Clyde Crumpacker; Jean Hurd from the 
alumni office; and others too numerous 
to mention for making this possible. ■ 



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35th— 1970 John (Tony) Davies 

Thirty two classmates, including three 
from the dental school, gathered for our 
35th reunion. The events flowed with 
out a hitch, thanks to the able guidance 
of Jean Hurd from the alumni office and 
our class reunion committee. Special 
recognition again goes to Joan Gold 
berg and Peter Gross for editing our 
reunion book. 

Thursday and Friday activities on the 
Quadrangle included symposia and 
alumni events. The Theatre Room at the 
Harvard Faculty Club in Cambridge was 
the venue for our well-attended dinner 
on Friday evening. Classmates and 
spouses enjoyed lively conversation dur- 
ing the social hour with wine, hors 
d'oeuvres, and a sumptuous buffet of 
salmon, chicken, and filet mignon. 
Although most classmates hailed from 
New England, others traveled from 
Guatemala, the Midwest, and the east- 
ern seaboard. This was Luis Villa's first 
HMS reunion, which he attended with 
his wife and son from Miami. 

Joan Goldberg and her husband, 
Fred, hosted the class for a lobster feast 
in the garden terrace of their Chestnut 
Hill home on Saturday. We sampled 
delicious cheeses and dips before din- 
ner and desserts after the meal. Later 
we retired to their air-conditioned liv- 
ing room to view with a few chuckles 
Tony Breuer's video of the class during 
our medical school days; we have not 
changed one iota in 35 years! We were 
delighted to be joined by Dan Feder- 
man '53 and his wife, Betty. 

Sunday brunch, attended by a select 
dozen, found us at the Jumbo Seafood 
restaurant in Newton sampling a great 
variety of tasty dim sum. The large, 
round table encouraged lively conversa- 
tion, while the enthusiastic waiter pre- 
sented more and more exotic dishes to 
satisfy our palates. 

In another live years, perhaps more 
classmates will have retired and be able 
to attend our 40th reunion. We look 
forward to sharing experiences of activ 
ities and relaxation in retirement. ■ 



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30th— 1975 Ramon Martin 

We could all remember when, as med 
ical students, we'd watch the alumni 
gather on the Quadrangle for Class Day 
and think: "They sure do look old." 
Thirty years out the tables have turned, 
and we observe the medical students 
sitting on the sidelines and remark at 
how young they seem. 

Remembering was an important part 
of our reunion activities. Twenty-four 
members of the Class of 1975 participat- 
ed. Henry Lerner, the class secretary, 
did an excellent job assembling the 
reunion book. 

After the class photo on the Quadran 
gle, we gathered in the Minot Room of 
Countway Library for dinner. Each per 
son received a copy of his or her initial 
class mug shot. We had a moment ol 
silence after the reading of the names of 

deceased classmates. During dinner, we 
raised a toast to the memory of Tom 
Wright, the grand administrator of Van- 
derbilt Hall during our days. We revisit- 
ed a drawing of the medical area that he 
made and decided to reproduce it to 
make it available to all classmates. We 
also toasted, in her absence, the recently 
retired associate dean for alumni pro- 
grams and special projects, Nora Ner- 
cessian, wishing her good health and 
enjoyment. The evening's conversation 
was brought to a close when Countway 
shut down for the night. 

We reconvened the following evening 
at the lovely home of Henry Lerner and 
Phyllis Scherr '84. The setting was per- 
fect for a great meal and conversation. 
When we parted, we all agreed that we 
should not wait live more years for 
another gathering like this one. ■ 



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25th— 1980 David Eisenberg and 
Lewis First 

Although it was only 25 years ago that 
the Class of 1980 graduated on the Quad- 
rangle, for many of us it seemed more like 
a quarter of a century. That being said, 
more than 60 members of our infamous 
class — along with family members and 
friends — gathered for three unforgettable 
days to reminisce and update each other 
on what has happened since we were 
medical students. 

Our weekend began with our sympo- 
sium, during which time we learned that 
our class has quite the diversified portfo- 
lio; classmates spoke about cutting- edge 
research, clinical care innovations, 
patient and global health advocacy, and 
new directions in medical education. 

We enjoyed two spectacular dinners, 
one held in the New Research Building 

and the other featuring a unique 12- 
course banquet at a Chinese seafood 
restaurant in Newton, followed by a 
Saturday afternoon clambake at the 
home of Joanne Wilkinson and her fam- 
ily in Walpole. 

Somehow between class photos and 
the presentation of our class gift on that 
Friday morning by Lynn McKinley- 
Grant and Hilda Hutcherson, we even 
managed to tind time to watch scenes 
from our Second and Fourth Year shows, 
as well as from the .Anatomy Awards we 
presented during our first year as stu- 
dents. While so much has changed on 
Longwood Avenue, it was wonderful to 
see the ties that bind our class together 
are tighter than ever. Thanks to all who 
helped with the planning of this great 
weekend. We look forward to seeing 
everyone at our 30th in 2010. ■ 


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,9 85 

20th— 1985 Michael Myers 

Members of the Class of 1985 came 
together in Boston to celebrate our 
20th reunion on June 10 and 11. [aney 
Wiggs and Tim Martinez HSDM '85 
helped to organize events (with lots of 
help from Jean Hurd in the alumni 
office). It was great to see folks from as 
far away as Puerto Rico, Texas, Indi 
ana. and California, as well as class- 
mates from Maine, Massachusetts, and 
New York. 

On Friday night we enjoyed a cock- 
tail reception in the New Research 
Building next to Vanderbilt Hall. Sat- 
urday's picnic on the Charles River 
was oppressively hot, but supportive 

spouses ran for more soda and ice, the 
kids didn't melt down (too much), and 
everyone agreed to make a big push for 
our 25th reunion in 2010. 

Some of the folks in attendance 
included Claire Bloom, Helen Hunt 
Bouscaren, Paulette Bryant-Lee, Joan 
Butterton, Janet Chaikind, Ed Flores 
and Cristela Hernandez Flores, Sandy 
Jo Jones, Lisa Kaufman, Phil Lane, Ginat 
Wintermeyer Mirowski and Steve 
Wintermeyer, Connie Monitto, Lisa 
Petri Henske, Maury Smith, Linda 
Starace Colabella, Libby Stewart, 
Sharee Umpierre-Catinchi, Kathleen 
Welsh, Jennifer Yolles, Suejane Grosso 
Mancene, and Susan Zweizig. ■ 



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15th— 1990 Eileen 

On Friday, after the morn- 
ing business meeting and 
symposium on communica 
tion in medicine, our class 
met for dinner at Davio's 
in Cambridge, where we 
had a beautiful view of the 
Charles River and the 
Boston skyline. 

Tiron and Marie Pechet 
^^ generously opened their 

Cambridge home for Satur 
day's afternoon picnic, where class- 
mates enjoyed catching up on each 
other's careers and lives. 

Thanks to all who helped organize 
the weekend, and we look forward to 
seeing each other again for our 20th 
reunion in 2010. ■ 




10th— 1995 Douglas Jutte 

It w T as a classic hot and humid Boston 
summer weekend when our small but 
rowdy group from the Class of 1995 got 
together for our tenth reunion. If I may 
say so, the most striking thing about see- 
ing old friends was how darned good 
everyone looked! Despite long years of 
residency and the many children scurry- 
ing about, no one seemed to have aged. 
Perhaps for HMS '95 the rumors are true, 
and 40 really will be the new 30! 

The weekend began with a handful of 
hard-core reunion-goers at the Alumni Day 
activities (and free lunch) on the Quad — 
just in time to hear that our own Rodney 
Taylor was elected as secretary for the Har- 
vard Medical Alumni Council. Apparently 
his popularity remains undiminished. 

In the evening the class convened on 
Newbury Street in Back Bay for sangria 
and tasty tapas. It wasn't long before 
Marissa Howard-McNatt's infectious 
laugh was ringing through the restaurant. 
There we discovered that George Tolis's 
disdain for political correctness remains 
intact; that Chan Raut was carjacked at 
gunpoint in Houston; that Sarah Wood 
and Mark Rubenstein are both metrosex- 
uals (yes, waxing is involved); that Keith 

and Katherine Dunlea\y had managed to 
leave all four of their children (yes, four) 
with Grandpa Kirby for the weekend; and 
that Monique Rainford has been working 
on her Jamaican accent — literally — in 
Kingston, where she now lives. 

On Saturday we met at Larz Anderson 
Park in Brookline, where children could 
run amok while adults hid in the shade 
and chowed down on barbeque. Some 
fresh faces included Chris Antenucci, 
Emily Oken, Carol Cardinale, and Benny 
Gavi — all with one or more kids in tow. 
Among the many children present were 
the mildly disconcerting "mini-me'' Julia 
(McHugh) Marine and Noah West; I've 
been reassured that no cloning was 
involved. For the barbeque stragglers, 
Michelle Finkel kindly opened her air- 
conditioned home and roof-deck where 
the evening wound down against the 
backdrop of the city skyline and the 
sounds of the nearby Theater District 
and Gay Pride Festival. 

The weekend reminded us of Boston's 
charms, of old friends, and of the often 
difficult but certainly memorable years at 
HMS. For pictures of the weekend, email 
me at And as Susan 
Spratt would say, "See ya'll next time!" ■ 



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5th— 2000 Sonia Batra 

Our class celebrated its fifth reunion 
with a small but dedicated group of 
alumni, with several classmates making 
the effort to travel from out of state. 
Our class now spans the gamut from 
residents, fellows, and attendings to 
business people, although the majority 
of us are still completing training. 

On Friday night, we enjoyed a deca- 
dent dinner at Maggiano's Little Italy in 
the Theater District. A miscalculation in 
the number of attendees — or perhaps a 
large number of no- shows (many of us 
are still on call house staff in Boston ) — 
left us far below our minimum food and 
beverage guarantee; we made up the dif 
ference with unforgettable fine wines 
(and several toasts to HMS 1 ) 

On Saturday, June 11, we braved the 
sweltering heat for a barbeque at Larz 
Anderson Park in Brookline. Although it 
took us some time to realize that all 
those familiar-looking people sharing 
the gazebo with us were in fact mem- 
bers of the Class of 1995 (and our former 
interns and residents during clinical 
rotations), our class had a respectable 
turnout. Our classmates introduced 
delightful new babies and children 
while we updated each other on our cur- 
rent job, marital, and life status. 

The weekend provided a wonderful 
opportunity to reconnect with one 
another and reminisce about our memo 
rable years at HMS, as well as catch up 
on all the adventures since. Hope to see 
e\ eryone at the tenth' ■ 




































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